GIFT  OF 
Pacific   Coast 

of 


LIPPINCOTT'S 
NURSING  MANUALS 


SURGICAL  AND  GYNECOLOGICAL 
NURSING 

BY 

EDWARD  MASON  PARKER,  M.D.,  F.A.C.S. 

Surgeon  to  Providence  Hospital,  Washington,  D.  C. 

AND 

SCOTT  DUDLEY  BRECKINRIDGE,  M.D.,  F.A.C.S. 
Gynaecologist  to  St.  Joseph's  Hospital,  Lexington,  Kentucky. 


LIPPINCOTT'S 

NURSING    MANUALS 

FULL  CATALOGUE  FREE  ON  REQUEST 

Ninth  Revised  Edition 

COOKE'S  HANDBOOK  OF  OBSTETRICS 

Revised  by 

CAROLYN  E.  GRAY,  R.N..AND  PHILIP  N.  WILLIAMS,  M.D. 
468  pages.     189  illustrations  and  4  full  pages  in  color. 

CARE  AND  FEEDING        Second  Edition 
OF  INFANTS  AND  CHILDREN 

A  TEXT-BOOK  FOR  TRAINED  NURSES 

By  WALTER  REEVE  RAMSEY,  M.D.,  of  University  of  Minnesota. 
280  pages.    123  illustrations. 

Second  Edition 

SURGICAL  AND  GYNECOLOGICAL  NURSING 

By  EDWARD    MASON   PARKER,  M.D.,  AND  SCOTT  DUDLEY 

BRECKINRIDGE,  M.D.,  of  Providence  Hospital,  Washington. 

D.  C.    425  pages.    134  illustrations. 

ESSENTIALS  OF  MEDICINE    Third  Edition 

By   CHARLES    PHILLIPS    EMERSON,   M.D.,  of  University  of 
Indiana.    401  pages.     117  illustrations. 

Second  Edition  Revised 

PHYSICS  AND  CHEMISTRY  FOR  NURSES 

By  A.  R.  BLISS,  M.D.,  Grady  Hospital,  Atlanta.  Ga..  AND  A.  H. 

OLIVE,  A.B.,  Phm.D.,  Hillman  Hospital,  Birmingham. 

239  pages.    49  illustrations. 

Third  Edition 

MATERIA  MEDICA  AND  THERAPEUTICS 

By  JOHN  FOOTE,  M.D.,  of  Providence  Hospital^  Washington,  D,  C. 
194  pages. 

FEVER  NURSING  Ninth  Edition 

By  J.  C.  WILSON,  M.D.,  of  Jefferson  Hospital,  Philadelphia. 
264  pages. 

PRACTICAL  BANDAGING     Second  Edition 

By  ELDRIDGE   L.  ELI^SON,  M.D.,  University  of  Pennsylvania 
Hospital.    li  i  pages.    155  illustrations. 

NURSING  AND  CARE          Third  Edition 
OF  THE  NERVOUS  AND  THE  INSANE 

By  CHAS.  K.  MILLS,  M.D.,  AND  N.  S.  YAWGER,  M.D. 
142  pages.     12  illustrations. 

HOW  TO  COOK  Fifth  Edition 

FOR  THE  SICK  AND  CONVALESCENT 

By  HELENA  V.  SACHSE.    337  pages. 

PRIVATE  DUTY  NURSING 

By  KATHERINE   DEWITT,  R.N.,  Assistant  Editor  of  American 
Journal  of  Nursing.     244  pages. 

ESSENTIALS  OF  SURGERY 

By  DR.  ARCHIBALD  G.  McDONALD 
288  pages.        Illustrated. 


LIPPINCOTT'S    NURSING    MANUALS 

SURGICAL  AND 

GYNECOLOGICAL 

NURSING 


BY 

EDWARD  MASON  PARKER,  M.D.,  F.A.C.S. 

SURGEON  TO  PROVIDENCE  HOSPITAL.  WASHINGTON,  D.  C. 
AND 

SCOTT  DUDLEY  BRECKINRIDGE,  M.D.,  F.A.C.S. 

GYN/ECOLOGIST   TO   ST.  JOSEPH'S   HOSPITAL,  LEXINGTON,  KENTUCKY 


WITH  134  ILLUSTRATIONS  IN  TEXT 
SECOND  EDITION.  REVISED 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


'  '  BIG 

LIBRARY 

GIFT  PACIFIC  OOAST  MOURN  At 
TO  HYGSrtE 


COPYRIGHT,  IQl6.   BY   J.    B.    LIPPINCOTT   COMPANY 
COPYRIGHT,   192  t,  BY  J.  B.  LIPPINCOTT  COMPANY 


Printed  by  J.  B.  Lippincott  Company 
The  Washington  Square  Press,  Philadelphia.  U.S.  A. 


8NX.CW7 

UBHAtY 


LIFE  is  SHORT,  ART  is  LONG,  OPPORTUNITY  FUGITIVE. 
EXPERIMENTING  DANGEROUS,  REASONING  DIFFICULT: 
IT  IS  NECESSARY  NOT  ONLY  TO  DO  ONESELF  WHAT  IS 
RIGHT  BUT  ALSO  TO  BE  SECONDED  BY  THE  PATIENT,  BY 
THOSE  WHO  ATTEND  HIM,  BY  EXTERNAL  CIRCUMSTANCES." 

HIPPOCRATES — The  Aphorisms. 


743623 


PREFACE  TO  THE  SECOND  EDITION 

IN  preparing;  the  second  edition  of  this  book  the  original 
arrangement  has  been  adhered  to.  The  introduction  of  new  mat- 
ter has  been  balanced  by  an  equal  condensation  and  elision,  so 
that  the  size  of  the  book  has  not  been  increased.  Many  minor 
changes  have  been  introduced  to  make  the  teaching  conform  to 
a  later  view  or  to  correct  some  points  which  we  believed  were 
open  to  just  criticism.  The  chapter  on  fractures  has  been  rewrit- 
ten and  other  chapters  have  been  revised  in  part.  The  surgical 
lessons  of  the  war  have  naturally  had  a  dominating  influence 
over  the  revision,  but  only  those  subjects  are  presented  which 
it  is  thought  will  be  found  of  value  in  civilian  nursing. 

The  most  important  addition  is  believed  to  be  the  chapter  on 
the  Carrel-Dakin  treatment  of  infected  wounds.  To  a  surgeon 
who  has  been  accustomed  to  the  smooth  working  of  a  Carrel- 
Dakin  unit  in  a  well  organized  Base  Hospital,  one  of  the  most 
annoying  difficulties  encountered  in  using  the  method  in  civil 
practice  is  the  lack  of  a  trained  nursing  team ;  while  to  a  surgeon 
who  has  not  had  the  advantage  of  that  experience  the  handicap  is 
even  greater,  for  books  on  the  subject,  written  for  the  surgeon,  do 
not  give  in  detail  that  part  of  the  exacting  technic,  which  falls 
to  the  nurse.  Nevertheless  the  obligation  to  employ  the  treat- 
ment in  severe  septic  conditions  (excluding  those  in  the  perito- 
neum), is  imperative,  since  by  its  means,  a  fulminating  infection, 
presenting  the  gravest  prognosis  under  any  of  the  older  methods, 
can  be  brought  back  to  the  safety  line  within  forty-eight  hours, 
and,  in  other  cases,  the  duration  of  morbidity  and  hospitalization 
can  be  shortened  by  weeks  or  months.  It  therefore  appears  that 
a  detailed  description  of  the  technic  from  the  nurse's  standpoint 
fills  a  definite  need. 

Our  thanks  are  due  to  Dr.  John  W.  Thomson  and  Dr.  Sewell 
N.  Pilchard  for  valuable  assistance  in  the  preparation  of  this 
chapter,  and  to-  Dr.  R.  Y.  Sullivan  and  Dr.  L.  A.  Martel  for 
criticisms  and  suggestions. 

EDWARD  M.  PARKER, 
SCOTT  D.  BRECKINRIDGE. 
WASHINGTON,  D.  C. 
March,  1921 

vii 


PREFACE 

THE  task  of  preparing  a  text-book  on  surgical  and  gynaeco- 
logical nursing  has  been  approached  with  considerable  hesitation 
and,  it  is  believed,  with  a  full  appreciation  of  the  difficulties  to 
be  encountered  and  the  obstacles  to  be,  if  possible,  surmounted. 
The  responsibility  of  deciding  as  to  the  relative  importance  to 
the  nurse  of  theory  as  opposed  to  practice  and  the  proportion 
of  such  a  book  that  should  be  devoted  to  each  has  proved  no 
light  one.  Nor  has  the  desire  to  present  all  theory  from  the 
viewpoint  of  its  practical  application  seemed  easy  of  fulfilment. 

The  effort,  throughout  the  preparation  of  this  volume,  has 
been  to  present  to  the  student  and  graduate  nurse  an  essentially 
practical  statement  of  those  procedures  in  her  professional  work 
that  fall  within  the  realms  of  general  surgery  and  gynaecology. 
While  fully  realizing  the  importance  of  a  clear  understanding  of 
the  theory  governing  the  practice  of  these  branches  of  nursing, 
it  has  not  appeared  either  necessary  or  desirable  to  attempt  the 
incorporation  of  the  theories  of  the  sister  branches  as  presented 
to  the  student  of  medicine.  As  a  consequence,  such  considera- 
tion as  may  be  given  to  surgical  bacteriology,  pathology,  sympto- 
matology or  treatment  has  been  with  the  sole  idea  of  emphasizing 
the  importance  of  certain  nursing  duties — as  the  sterilization  of 
instruments  and  dressings,  the  accurate  noticing  and  recording 
of  signs  and  symptoms,  or  the  preparation  of  materials  necessary 
for  the  proper  surgical  treatment  of  specified  conditions. 

The  unusual  amount  of  space  (both  textual  and  illustrative) 
given  to  the  subject  of  surgical  instruments  was  planned  with  the 
hope  that  it  would  give  a  chance  to  the  nurse  for  preparation 
before  she  is  thrown  into  the  thick  of  the  operating-room  fray. 
Even  a  general  idea  of  the  names,  appearances,  and  uses  of  the 
instruments  she  is  to  handle,  together  with  some  knowledge  of 
their  routine  application  and  order  of  use,  should  spare  the  novice 
at  least  some  part  of  the  discouragement  and  confusion  to  which 
she  is  subject  under  the  operating-room  systems  of  many 
hospitals. 

In  addition  to  those  portions  of  the  book  that  are  strictly 
surgical  in  their  application,  there  has,  necessarily,  been  some 

ix 


x  PREFACE 

consideration  of  border-line  subjects.  Under  this  classification 
might  come  such  chapters  as  the  one  on  the  use  of  fractional 
doses  in  hypodermic  medication  and  the  one  upon  weights, 
measures,  solutions  and  formulae.  The  excuse  for  the  presence 
of  these  particular  chapters  must  be  based  upon  the  existence 
of  an  apparent  necessity  for  the  consideration  of  these  subjects — 
particularly  in  their  connection  with  surgical  nursing. 

Throughout,  the  desire  has  been  constant  to  prepare  a  text- 
book that  would  supply  those  needs  that  were  most  apparent 
to  the  lecturer  and  the  operator,  without  neglecting  that  part 
of  *the  field  that  had  already  been  fully  and  successfully  covered. 
It  only  remains  to  be  hoped  that  the  completed  volume  will,  to 
some  extent,  fulfil  this  wish. 

Many  thanks  are  due  to  Captain  Christie,  Medical  Corps, 
U.  S.  A.,  and  to  Sergeant  Cahill,  of  the  Army  Hospital  Corps, 
for  assistance  with  the  illustrations  of  instruments;  to  Lenz  & 
Lossau  for  the  loan  of  surgical  instruments;  to  the  Superintendent 
of  Nurses  at  Providence  Hospital  for  valuable  suggestions  and 
aid;  to  Mr.  William  Kearny  Carr  for  the  privilege  of  using  some 
of  his  beautiful  microphotographs  of  bacteria;  and  to  Dr.  R.  M. 
Le  Comte  for  the  loan  of  a  number  of  examples  of  the  work  of 
that  past-master  of  microphotography,  the  late  Dr.  William  M. 
Gray.  Undoubtedly  our  greatest  single  obligation  is  to  Miss 
Isabel  M.  Stewart,  of  Teachers'  College,  Columbia  University, 
who  has  reviewed  the  entire  manuscript,  and  whose  criticisms 
and  suggestions  have  pointed  the  way  to  a  rather  thorough 
revision  both  of  the  subject  matter  and  arrangement  of  the  book 
to  its  very  great  advantage.  Our  thanks  are  particularly  due 
also  to  Dr.  George  W.  Crile  for  his  kindness  in  reading  and  criti- 
cising the  chapter  on  anoci-association.  Finally  we  desire  to 
express  our  grateful  appreciation  to  the  J.  B.  Lippincott  Company 
for  their  constant  courtesy  and  forbearance  throughout  a  some- 
what tedious  siege. 

EDWARD  M.  PARKER, 

ScoTT  Dt  BBECKINBIDGE- 


CONTENTS 


PART  I 
INFECTION 

CHAPTER  PAGE 

I.  THE  CELLS  OF  THE  BODY  AND  THE  INVADING  CELLS 3 

Historical  Introduction.  The  Cell:  Form  and  Structure;  Activi- 
ties; Vital  Requirements — Moisture,  Food,  Temperature;  Qual- 
ities of  the  Cell — Irritability,  Adaptability,  Specialization,  Con- 
stant Change,  Continuity  of  Life,  Stability.  Single-celled  Organ- 
isms. Many-celled  Organisms.  Health  and  Disease.  Infection. 
Single-celled  Organisms  Concerned  in  Infection:  Bacteria;  Pro- 
tozoa; Yeasts  and  Moulds;  Filterable  Viruses,  Unknown  Invaders. 

II.  THE  SOURCES  AND  MODES  OP  INFECTION 25 

Number  of  Species  Concerned.  Distribution:  In  Air;  in  Water; 
in  the  Soil;  in  Food;  in  the  Human  Body.  Relation  of  Parasite 
to  Host.  Carriers  of  Disease  Organisms.  Modes  of  Transmission. 

III.  INFECTION  IN  WOUNDS 34 

Definitions.     Operative   Wounds.     Normal    Healing.     Infected 
Wounds.    Healing  in  Infected  Wounds.    Sources  and  Modes  of 
Septic  Wound  Infection.     Bacteria  Concerned  in  Wound  Infec- 
tion:  Staphylococcus  Pyogenes  Aureus;  Streptococcus  Pyogenes; 
Colon  Bacillus;  Bacillus  Pyocyaneus.     Other  Infections  of  Im- 
portance in  Surgery:    Tetanus;  Gas  Bacillus;  Tubercle  Bacillus; 
Organism  of  Syphilis;  Gonococcus. 

PART  II 
THE  FIELD  OF  SURGERY 

IV.  SURGICAL  PATHOLOGY 55 

Definitions:     Affection;   Disease;  Etiology;   Lesion;  Symptom; 
Physical  Signs;  Signs;  Diagnosis;  Treatment;  Pathology.    Mean- 
ing of  Pathological  Changes.    Causes  of  Disease:     Mechanical; 
Physical;    Chemical.      Changes    in    Cell   Activities:     Adaptive 
Changes — Examples     of     Adaptive     Changes,     Compensatory 
Changes,  Primary  Adaptive  Changes  Which  Occur  in  Accidental 
and   Operative  Wounds,    Inflammation,   The   Healing   Process, 
Healing  by  Granulation,  Defences  of  the  Body  Against  Infec- 
tion; Perverted  Cell  Activities.    Tissue  Changes :    Constructive — 
Repair,    Hypertrophy,    Tumor   Formation;   Destructive   Tissue 
Changes — Atrophy,  Necrosis;  Cell  Degenerations.    Disturbances 

of  General  Function, 

xi 


xii  CONTENTS 

V.  SURGICAL  AND  GYNAECOLOGICAL  NOMENCLATURE 83 

General  Derivation;  Method  of  Construction;  Root-wonis; 
Prefixes;  Suffixes;  Abbreviations. 

VI.  THE  SURGICAL  FIELD 89 

Outline  of  the  Surgical  Field :  Affections  Not  Caused  by  Disease 
— Anatomical  Defects,  Mechanical  Derangements,  Foreign 
Bodies,  Trauma;  Diseases  and  Affections  Arising  from  Disease — 
Infections,  New-growths,  Other  Organic  Diseases,  Functional 
Diseases.  Surgical  Specialism:  Ophthalmology;  Otology;  Laryn- 
gology and  Rhinology;  Gynaecology;  Geni to-urinary  Surgery; 
Orthopaedic  Surgery;  Surgery  of  the  Nervous  System;  General 
Surgery.  Operative  Surgery :  Nomenclature ;  Operative  Hazards ; 
Mortality;  Morbidity;  The  Surgical  Obligation. 

PART  III 

MINOR  TECHNIC  IN  SURGICAL  NURSING 

VII.  POSTURES 101 

The  Horizontal  Recumbent  Position;  Trendelenburg  Position; 
Reversed  Trendelenburg  Position;  Dorsal  Position;  Dorsal  Ele- 
vated Position;  Dorsosacral  (Lithotomy)  Position;  Elevated 
Dorsosacral  Position;  Right  and  Left  Lateral-prone  Position; 
Knee-chest  Position;  Erect  Position.  Variations  from  the  Usual 
Arrangement  and  Equipment  in  Operations:  Trendelenburg; 
Lithotomy;  Knee-chest  Position. 

VIII.  BANDAGING 109 

Principles  of  Bandaging:  Those  That  Concern  Efficiency; 
Those  That  Concern  Neatness.  Forms  and  Uses  of  Bandages. 
Materials  and  Preparation.  Application  of  the  Roller  Bandage. 
Bandaging  for  the  Fixation  of  Dressings.  Bandaging  for  Pres- 
sure. The  "Turns"  Used  in  Bandaging.  Regional  Bandaging: 
The  Head,  the  Neck,  the  Thorax,  the  Abdomen,  the  Extremities. 
Plaster- of-Paris  Bandages  and  Casts. 

IX.  FRACTURES 134 

Treatment  of  Fractures;  Traction  and  Fixed  Extension;  Splints; 
Accessory  Apparatus;  Assembling  Materials;  Observation  after 
the  Dressing  of  Fractures. 

X.  REMEDIAL  MEASURES 143 

The  Enema;  Rectal  Irrigation;  Continuous  Proctoclysis;  Active 
and  Passive  Congestion;  Paraffin  Occlusion  Treatment  for  Burns; 
Fowler  Position;  Special  Forms  of  Dressings;  Hypodermic  Medi- 
cation; Catheterization;  Bladder  Irrigation;  Vaginal  Douche; 


CONTENTS  xiii 

Changing  of  Perineal  Dressings.  The  Dressing  Room;  the  Dress- 
ing Cart;  Dressing  of  Abdominal  Wounds;  Hypodermoclysis; 
Intravenous  Infusion  of  Physiological  Salt  Solution;  Uterine 
and  Vaginal  Packing. 

XL  THE  CARREL-DAKIN  TECHNIC 160 

Infected  Wounds  in  World  War.  Conditions  of  the  Problem. 
Dakin  Solution.  Outline  of  Carrel  Technic.  Effects  of  Dakin 
Solution.  Preparation  of  Materials.  Articles  on  Dressing 
Carriage.  Routine  Dressing  Rounds.  Duties  of  Nurse  in 
Intervals  Between  Dressings.  Chloramines. 

XII.  WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULA 169 

Weights  and  Measures:  Linear  Measure;  Measures  of  Volume; 
Measures  of  Weight;  Transposition  of  Tables.  Solutions.  For- 
mulae: For  Local  Anaesthetics;  for  Antiseptic  Solutions;  for 
Enemata;  for  Saline  Solutions;  for  Ointments  and  Pastes;  for 
Vaginal  Douches;  for  Depilatory  Powder.  Making  Solutions 
from  Pure  Drugs.  Making  Solutions  from  Stock  Solutions. 

XIII.  CHARTS  AND  RECORDS 180 

The  Chart:  Cover  Sheet;  Temperature  Sheet;  Record  Sheet; 
Medicine  and  Treatment  Sheet. 


PART  IV 

THE  PATIENT 

XIV.  OBSERVATION 189 

The  Nurse  as  an  Observer.  The  Meaning  of  Observation. 
Method  in  Observation.  The  Significance  of  Symptoms.  Con- 
ditions Which  Require  That  the  Surgeon  Should  be  Called. 
Objective  Symptoms  and  Signs.  Subjective  Symptoms:  Those 
Connected  with  the  Special  Senses;  Pain;  Organic  Sensations; 
Feelings.  Measurements  and  Quantitative  Estimations:  Meas- 
urement, Quantitative  Estimation,  the  Scale  of  Seven;  the 
Record. 

XV.  MEASURES  FOR  THE  COMFORT  AND  WELL-BEING  OP  THE  PATIENT  201 
The  Work  Done  by  the  Nurse  Without  General  or  Special  Orders. 
Position  in  Bed.  Application  of  Heat  and  Cold.  Measures 
for  Relief  of  Pain.  Water  and  Food.  Attention  to  Bandages 
and  Dressings.  Precautions  in  Acutely  Infected  Cases :  For  the 
Patient;  for  the  Household  or  Other  Patients;  for  the  Nurse. 


xiv  CONTENTS 

XVI.  ROUTINE  NURSING  IN  OPERATIVE  CASES 213 

Preparation  of  the  Patient  for  Operation:  Bowel  Function; 
Diet;  Field  of  Operation.  Routine  Treatment  after  Operation : 
Minor  Steps  for  Comfort  of  the  Patient;  Administration  of 
Water;  Nourishment;  Bladder  Function;  Bowel  Function; 
Opiates;  Dressings;  Sitting  Up;  Going  Home;  Belts,  Binders 
and  Supports. 

XVII.  POST-OPERATIVE  COMPLICATIONS 222 

Shock.  Hemorrhage.  Acute  Dilatation  of  the  Stomach. 
Intestinal  Obstruction.  Infections:  Local  Infections;  Sa- 
praemia;  Peritonitis;  Septicaemia;  Pyaemia;  Pulmonary  Com- 
plications: Lobar  Pneumonia;  Bronchopneumonia.  Urinary 
System:  Retention  of  Urine;  Retention  with  Overflow; 
Incontinence  of  Urine;  Suppression  of  Urine. 

XVIII.  ANOCI-ASSOCIATION 229 

Shock  and  Fear.  The  Technic  of  Anoci-association.  The 
Nurse's  Part  in  the  Anoci-association  Technic. 

PART  V 
THE  OPERATION 

XIX.  THE  OPERATING  ROOM,  ITS  OUTFIT  AND  SUPPLIES 243 

Organization.  The  Operating  Suite.  Fixtures:  Sterilizers — 
Hot-air  Sterilizer,  Autoclave,  Instrument  Sterilizer,  Utensil 
Sterilizer,  Water  Sterilizers.  Operating-room  Furniture. 
Supplies. 

XX.  OPERATING  MATERIAL 261 

Classification.  Materials  Which  Come  into  Temporary  Con- 
tact with  the  Wound.  Materials  Which  are  to  Remain  in  the 
Wound  for  a  Time  or  Permanently:  Method  of  Preparing 
Catgut  Sutures  and  Ligatures.  Materials  for  Fixation  of 
Wound  Dressings.  Methods  of  Assembling  and  Sterilizing 
Operating  Material. 

XXI.  SURGICAL  INSTRUMENTS 278 

Cutting  Instruments;  Clamping  Instruments;  Holding  Instru- 
ments; Exposing  Instruments;  Sewing  Instruments;  Auxiliary 
Instruments;  Care  of  Instruments. 

XXII.  THE  ASEPTIC  TECHNIC 296 

Definitions.  First  Principles  of  Asepsis.  Sterilization  by 
Heat.  Outlines  of  the  Aseptic  Technic:  Methods  of  Sterili- 
zation; Assembling  and  Handling  the  Sterilized  Outfit;  Prep- 
aration of  Members  of  the  Clean  Group;  Conduct  During  the 
Operation;  Conduct  Between  Operations.  The  Super-technic. 
Breaks  in  the  Aseptic  Technic. 


CONTENTS  xv 

XXIII.  PREPARATION    FOR   AN   OPERATION    AND    THE    OPERATING- 
ROOM  PERSONNEL 311 

Necessary  Preparations — For  the  Patient,  for  the  Anaesthe- 
tist, for  the  Operator  and  Assistants,  for  the  Scrubbed  Nurses, 
for  the  Unscrubbed  Nurse.  Preparation  of  the  Nurse:  Cap, 
Scrub,  Gown  and  Gloves.  The  Operating-room  Personnel: 
Anaesthetist;  the  Operator;  the  First  Assistant;  the  Second 
Assistant;  the  Nurse  in  Charge  of  the  Instruments;  the 
Nurse  in  Charge  of  the  Sponges;  the  Unscrubbed  Nurse; 
the  Orderly.  Duties  of  Operating-room  Nurses:  The  Un- 
scrubbed Nurse;  Instrument  and  Suture  Nurse;  Sponge 
Nurse.  Care  of  the  Anaesthetized  Patient.  Application  of 
the  First  Dressing.  Care  of  the  Patient  after  Operation. 

XXIV.  SELECTION  OF  INSTRUMENTS 323 

The  Dissecting  Set;  General  Abdominal  Set;  Appendix  Set; 
Gall-bladder  Set;  Stomach  and  Intestine  Set;  Kidney  Set; 
Pelvic  Set;  Hernia  Set;  Extensive  Dissecting  Set;  Rectal 
Set — For  Hemorrhoids,  for  Fissure  or  Fistula  in  Ano,  for 
Resection;  Female  Perineal  Set;  Uterine  Curettage  Set; 
Trachelorrhaphy  Set;  Perineal  Prostatectomy  Set;  Cranial 
Set;  Amputation  Set.  Wiring  or  Plating  Set;  Resection  Set; 
Osteomyelitis  Set. 

XXV.  OPERATIVE  STEPS 336 

Operations  upon  the  Head:  Trephining;  Craniotomy. 
Operations  upon  the  Trunk:  Resection  of  Rib;  Gall-bladder 
Operations;  Appendectomy;  Radical  Cure  of  Inguinal  Hernia; 
Shortening  of  Round  Ligaments;  Hysterectomy;  Dilatation 
and  Curettage  of  Uterus;  Trachelorrhaphy;  Perineorrhaphy. 
Operations  upon  the  Extremities:  Amputation  Through  the 
Thigh;  Disarticulation  at  the  Shoulder. 

XXVI.  OPERATIONS  IN  PRIVATE  HOUSES 345 

The  Room;  the  Table;  Utensils  and  Supplementary  Supplies; 
Artificial  Light;  Substitutes  for  Lithotomy  Posts;  Kelly  Pad; 
Anaesthetic;  Sterilization  of  Instruments,  Water,  etc. 

PART  VI 

SUPPLEMENTARY  CHAPTERS 

XXVII.  GYNAECOLOGICAL  DISPENSARY 351 

Records;  Examining  and  Treatment  Room;  Instruments; 
Preparation  for  Examination;  Drugs,  Solutions,  etc.;  Draping 
of  Patient  for  Examination. 


xvi  CONTENTS 

XXVIII.  EMERGENCIES 356 

Accidents.  Wounds.  Burns.  Fractures:  Compound; 
Simple;  Fractures  at  the  Wrist;  of  the  Forearm;  at  the 
Elbow- joint;  of  the  Upper  Arm  and  of  the  Clavicle;  of  the 
Leg,  Ankle  and  Foot;  of  the  Thigh;  of  the  Jaw;  of  the  Ribs; 
Dislocation;  Injuries  of  the  Knee;  of  the  Ankle;  of  the  Hip. 
Diagnosis  of  Injuries.  Transportation  of  Patients.  Hemor- 
rhage: Methods  of  Controlling  Hemorrhage — Elevation, 
Digital  Compression,  Flexion,  the  Tourniquet,  Pressure  by 
a  Bandage,  Packing  the  Wound,  Direct  Pressure,  Heat  and 
Cold,  Styptic  or  Astringent  Drugs;  Indications  for  the  Con- 
trol of  Hemorrhage  According  to  Character  and  Location. 
Artificial  Respiration.  Shock  hi  Accident  Cases. 

XXIX.  THE  PERSONAL  ATTITUDE  OF  THE  NURSE 372 

Attitude  to  the  Patient.  Attitude  to  the  Surgeon.  Attitude 
to  the  Hospital.  Attitude  to  the  Public.  Attitude  to  Self. 

XXX.  AN  EPITOME  OF  SOME  COMMON  SURGICAL  AND   GYNAECO- 
LOGICAL CONDITIONS 377 

Congenital  Deformities  and  Defects :  Cleft  Palate  and  Hare- 
lip; Spina  Bifida;  Other  Congenital  Defects.  Acquired  De- 
formities. Foreign  Bodies.  Trauma:  Definition;  Lesions; 
Symptoms  and  Signs;  Wounds  of  Special  Structures;  Treat- 
ment. Surgical  Infections:  Sepsis.  Septic  Diseases:  Ery- 
sipelas; Phlegmon;  Abscess;  Sepsis  in  Bone,  hi  Joints,  in 
Serous  Cavities.  Treatment  and  Nursing.  Surgical  Tuber- 
culosis. Tetanus.  New-growths:  Classification;  Benign 
Tumors;  Malignant  Tumors;  Tumors  in  Special  Tissues. 
Other  Organic  Diseases:  Goitre;  Aneurism;  Gangrene. 
Diseases  of  the  Abdomen;  Ulcer  of  the  Stomach  and  Duo- 
denum; Cancer  of  the  Stomach  and  Intestines;  Appendicitis; 
Intestinal  Obstruction;  Tuberculous  Peritonitis;  Hernia;  Gall- 
stone Disease.  Gynaecological  Diseases :  Malformations  and 
Displacements;  Atresia  of  the  Vagina;  Anteflexion  of  the 
Uterus;  Retro  version  of  Uterus;  Prolapse  of  Uterus.  Injuries : 
Laceration  of  Cervix;  Laceration  of  Perineum;  Genital  Fistulse. 
Inflammations:  Vulvitis;  Endometritis;  Salpingitis.  New- 
growths:  Ovarian  Cysts;  Fibroid  Tumors  of  the  Uterus; 
Cancer  of  the  Uterus. 


ILLUSTRATIONS 


FIG,  PAQB 

1.  Diagram  of  a  Cell 9 

2.  Multiplication  of  a  Cell  (Craig) 10 

3.  Showing  Relative  Size  of  Bacteria 19 

4.  Diphtheria  Bacilli  (Carr) 20 

5.  Spirilli  of  Asiatic  Cholera  (Carr) 20 

6.  Bacillus  Subtilis,  Showing  Flagellae  (Gray) 21 

7.  Diplococcus  Pneumoniae  (Carr) 21 

8.  Streptococci  (Gray) 21 

9.  Staphylococci  (Carr) 21 

10.  Bacilli  Showing  Spores  (Parker) 21 

11.  Chart  Showing  Normal  Temperature  After  Operation 38 

12.  Chart  Showing  Traumatic  Temperature  (Miss  Kathleen  Carroll) .  .  39 

13.  Chart  Showing  Septic  Infection  (Local  Abscess)  After  Operation. .  .  40 

14.  Chart  Showing  Septic  Infection,   Continued  Type   (Miss  Emily 

Warren) 43 

15.  Staphylococcus  Pyogenes  (Carr) 47 

16.  Streptococcus  Pyogenes  (Parker) 47 

17.  Bacillus  Coli  Communis,  Showing  Flagellae  (Gray) 48 

18.  Bacillus  Pyocyaneus,  Showing  Flagellae  (Gray) 48 

19.  Bacillus  Tetani,  Showing  Flagellae  (Gray) 49 

20.  Bacillus  Tetani,  Showing  Spores  (Carr) 49 

21.  The  Gas  Bacillus  (Parker) 50 

22.  Tubercle  Bacilli  (Carr) 50 

23.  Treponema  Pallidum  (Gray) 51 

24.  Micrococcus  Gonorrhceae  (Wood) 52 

25.  Frog's  Mesentery,  Normal  (Agnew) 68 

26.  Frog's  Mesentery,  Inflamed  (Agnew) 68 

27.  Emigration  of  Leucocytes  (Wood) 69 

28.  Section  Through  Skin  of  Guinea-pig  Eight  Hours  After  a  Wound 

(Shakespeare) 70 

29.  Same  at  Later  Stage  (Shakespeare) 71 

30.  The  Same  Later  (Shakespeare) 72 

31.  Cicatrix  Formed  in  the  Wound  (Shakespeare) 73 

32.  Healing  of  a  Wound  by  Granulation  (Wood) 74 

33.  Varieties  of  Blood-cells 75 

34.  Amoeba  Coli  (Entamoeba  Dysenteriae),  Common  Form 75 

35.  Phagocytosis  (Wood) 77 

36.  Horizontal  Recumbent  Position 102 

37.  Trendelenburg  Position 102 

38.  Dorsal  Position 103 

39.  Dorsosacral  (Lithotomy)  Position 104 

40.  Right  Lateral-prone  Position 105 

41.  Genu-pectoral  (Knee-chest)  Position 106 

42.  Triangular  Bandage  (Eliaaon's  Practical  Bandaging) Ill 

xvii 


xviii  ILLUSTRATIONS 

43.  Single  T-Bandage Ill 

44.  Four-tailed  Bandage Ill 

45.  Modified  Bandage  of  Scultetus 112 

46.  Rolling  Bandage  by  Hand 113 

47.  Bandage  Roller 114 

48.  Circular  Turns  of  a  Bandage  (Eliason's  Practical  Bandaging) 118 

49.  Spiral  and  Oblique  Turns  (Eliason's  Practical  Bandaging) 119 

50.  Making  Reverses 120 

51.  Figure-of-Eight  Turns  (Eliason's  Practical  Bandaging 121 

52.  Spica  of  the  Hip 122 

53.  Recurrent  of  the  Scalp  (Eliason's  Practical  Bandaging) 122 

54.  Recurrent  Bandage  of  the  Stump 122 

55.  Recurrent  Turns  (Eliason's  Practical  Bandaging) 123 

56.  Figure-of-Eight  of  the  Head  and  Neck  (Eliason's  Practical  Ban- 

daging)   123 

57.  Double  Oblique  of  the  Jaw  (Eliason's  Practical  Bandaging) 123 

58.  Four-tailed  Bandage  of  the  Chin  (Eliason's  Practical  Bandaging) . .  123 

59.  Barton's  Bandage 124 

60.  Gibson  Bandage  (Eliason's  Practical  Bandaging) 124 

61.  Spiral  Reverse  of  Lower  Extremity  (Eliason's  Practical  Bandaging)  126 

62.  Velpeau  Modified  (Dulles)  (Eliason's  Practical  Bandaging) 127 

63.  Desault  Bandage  (Eliason's  Practical  Bandaging) -. 128 

64.  Finger  Bandage 129 

65.  Spica  of  the  Foot  (Eliason's  Practical  Bandaging) 129 

66.  Method  of  Squeezing  Water  from  Bandage   (Eliason'a  Practical 

Bandaging) 131 

67.  Making  Plaster  Bandages  (Eliason's  Practical  Bandaging). 131 

68.  Instruments  for  Removing  Plaster  Casts  (Eliason'a  Practical  Ban- 

daging)   132 

69.  Thomas  Splint 138 

70.  Balkan  Frame 140 

71.  Median  Section  of  Female  Pelvis 144 

72.  Apparatus  for  Proctoclysis 148 

73.  Showing  Notch  Filed  in  Stop-cock 149 

74.  Tubes,  Syringe  and  Chart  for  Carrel- Dakin  Method 165 

75.  Chart  Showing  Morning  and  Evening  Temperature  (Septic  Perito- 

nitis)    181 

76.  Four-hour  Chart  (Septicopyemia) 182 

77.  Type  of  Record  Sheet 183 

78.  Medicine  and  Treatment  Sheet 185 

79.  Operating  Room 245 

80.  Sterilizing  Room ! 246 

81.  Hot-Air  Sterilizer 247 

82.  Autoclave 248 

83.  Autoclave  with  Drums  for  Dressings 249 

84.  Instrument  Sterilizer 250 

85.  Utensil  Sterilizer 251 

86.  Water  Sterilizers. .  .  252 


ILLUSTRATIONS  xix 

87.  Operating  Table 253 

88.  Drums  on  Stand 254 

89.  Irrigator  Stand 255 

90.  Needle  and  Thread  for  Arterial  Suture  (Bernheim) 276 

91.  Flask  for  Arterial  Sutures 276 

92.  Cutting  Instruments:  Knives  and  Scissors 279 

93.  Cutting  Instruments :  Bone  Drills  and  Trephines 280 

94.  Cutting  Instruments:  Curettes 280 

95.  Cutting  Instruments:  Bone  Cutters 281 

96.  Cutting  Instruments:  Chisels  and  Gouges 281 

97.  Cutting  Instruments:  Bone  Saws 282 

98.  Clamping  Instruments:  Haemostatic 284 

99.  Clamping  Instruments 284 

100.  Clamping  Instruments 284 

101.  Clamping  Instruments:  Intestinal  Clamps 284 

102.  Holding  Instruments 285 

103.  Holding  Instruments 285 

104.  Exposing  Instruments:  Retractors 286 

105.  Exposing  Instruments:  Retractors 287 

106.  Exposing  Instruments:  Retractors 287 

107.  Exposing  Instruments:  Specula 288 

108.  Exposing  Instruments:  Specula  (Vaginal) 288 

109.  Surgical  Needles 289 

110.  Needle  Holders 291 

111.  Sewing  Instruments:  Ligature  and  Suture  Carriers 291 

112.  Auxiliary  Instruments:  Probes,  Directors,  Dissectors 292 

113.  Auxiliary  Instruments:  Dilators 292 

114.  Auxiliary  Instruments:  Dilators 294 

115.  Auxiliary  Instruments:  Evacuators  (Catheters) 294 

116.  Auxiliary  Instruments:  Evacuators  (Trocars  and  Cannulae) 294 

117.  Diagram  of  Arrangement  of  Operating  Room 316 

118.  Showing  Improper  Position  of  Arm 320 

119.  Pillow  Support  Under  Back 321 

120.  Instruments:  the  Dissecting  Set 324 

121.  Additions  for  General  Abdominal  Set 324 

122.  Additions  for  Gail-Bladder  Set 326 

123.  Additions  for  Pelvic  Set 326 

124.  Additions  for  Hemorrhoid  Set 328 

125.  Additions  for  Female  Perineal  Set 328 

126.  Uterine  Curettage  Set 330 

127.  Cranial  Set 330 

128.  Bone  and  Cranial  Set 332 

129.  Amputation  Set 332 

130.  Joint  Resection  Set 333 

131.  Rib  Resection  Set 334 

132.  Osteomyelitis  Set 334 

133.  Shafer  Method  of  Artificial  Respiration,  First  Position 370 

134.  Shafer  Method  of  Artificial  Respiration,  Second  Position 370 


1 ' 


PART  I-INFECTION 


SURGICAL  AND 
GYNECOLOGICAL  NURSING 

CHAPTER  I 

THE  CELLS  OF  THE  BODY  AND  THE  INVADING  CELLS 

MODERN  surgery  may  be  said  to  owe  the  whole  of  its  wonder- 
ful advancement  to  the  invention  of  a  single  instrument,  the 
purpose  and  uses  of  which  were  so  far  removed  from  the  obvious 
needs  of  the  surgeon  that  not  the  wildest  dreamer  could  have 
guessed  its  epoch-making  importance  in  relation  to  surgical 
practice.  The  immensely  widened  field  of  vision  which  the 
microscope  opened  up  to  the  students  of  living  matter  resulted 
finally,  among  many  other  benefits,  in  freeing  surgery  from  the 
terrible  handicap  of  wound  infection  under  which  it  had  labored 
for  more  than  a  score  of  centuries.  •  Under  this  handicap  surgical 
operations  which  are  now  considered  trivial  and  practically 
devoid  of  risk,  were  attended  with  a  huge  mortality,  and  almost 
every  form  of  operative  interference  involving  the  deeper  parts 
of  the  body  was  absolutely  prohibited  by  death  in  practically 
all  the  cases.  All  the  great  serous  cavities  of  the  body  were  thus 
placed  beyond  the  possibility  of  surgical  exploration.  Abdomi- 
nal surgery  was  an  almost  untouched  field,  surgical  manipulation 
within  the  thoracic  or  cranial  cavities  undreamed  of.  Trephining 
the  skull  was  a  very  ancient  operation,  it  is  true,  but  only  the 
boldest  surgeon  ever  ventured  to  cut  through  the  lining  mem- 
brane of  the  cranium  which  encloses  the  brain,  and  none  dared 
repeat  the  venture  often.  John  Hunter,  greatest  English  surgeon 
of  his  time,  declared  that  he  never  saw  a  case  recover  where  the 
dura  mater  had  been  either  wounded  or  incised  at  an  operation. 
Even  in  the  more  external  parts  of  the  body  wounds,  whether 
operative  or  accidental,  except  the  most  trivial,  resulted  in  a 
dreadful  proportion  of  fatalities.  The  amputation  of  limbs,  even 

3 


4  INFECTION 

in  the  most  skilful  hands,  had  a  mortality  of  forty  per  cent,  or 
more.  Of  compound  fractures  of  the  thigh  treated  during  the 
Napoleonic  wars  over  eighty  per  cent,  were  fatal.  The  menace 
of  septic  disease  in  \vounds  naturally  increased  in  proportion  as 
patients  were  brought  together  in  large  hospitals,  so  that  the 
very  circumstance  which  would  otherwise  have  favored  progress, 
by  giving  to  the  surgeon  the  advantage  of  an  enlarged  experience, 
became  the  means  of  retarding  every  effort  at  improvement  in 
operative  work  by  the  almost  prohibitive  death  rate  which  it 
imposed. 

The  emancipation  of  surgery  from  the  bonds  which  had  so 
long  confined  it  began  with  the  work  of  Joseph  Lister,  following 
the  lead  of  the  great  Frenchman,  Louis  Pasteur.  The  time  was 
peculiarly  ripe  for  the  triumph  which  Lister  was  destined  to 
achieve.  Anaesthesia  by  means  of  ether  and  chloroform  had 
been  discovered  and  had  now  been  an  established  procedure  in 
surgical  practice  for  more  than  a  decade.  To  make  clear  the 
full  meaning  of  this  innovation  it  is  necessary  to  point  out  that 
its  benefits  were  of  two  kinds.  The  '  'Death  of  Pain,"  inestimable 
boon  though  it  was  for  the  patient,  was  of  far  less  importance 
from  the  larger  outlook  than  the  opportunity  now  given  to  the 
surgeon  of  doing  his  work  with  deliberate  care.  In  pre-anses- 
thetic  days  surgical  operations  had  to  be  done  at  the  highest 
attainable  speed.  Two  or  three  minutes,  for  example,  was  the 
record  for  an  amputation  which  every  surgeon  strove  to  equal 
or  surpass.  With  the  introduction  of  anaesthesia  all  this  was 
changed.  Hours  instead  of  minutes  were  now  available  if  neces- 
sary. The  dexterity  of  the  juggler  ceased  to  be  the  ideal  for  the 
work  of  an  operating  surgeon,  and  the  painstaking  skill  of  an 
expert  handicraftsman  took  its  place.  As  a  consequence  the 
temptation  to  try  out  improved  methods  and  new  operations 
was  almost  irresistible,  and  surgeons  everywhere  were  pressing 
restlessly  against  the  limitations  which  the  huge  mortalities 
from  sepsis  still  imposed  upon  them.  A  quarter  of  a  century 
earlier  a  great  German  anatomist  had  been  the  first  to  formulate 
clearly  the  theory  of  a  living  contagion;  our  own  Dr.  Oliver 
Wendell  Holmes  had  pointed  out  the  contagious  nature  of  puer- 
peral fever,  and  had  suggested  the  employment  of  chemical  dis- 
infectants as  a  safeguard  against  it;  in  the  obstetric  wards  of  a 
great  hospital  in  Vienna  such  measures  had  been  put  to  the  test 
of  practical  use  with  marked  success;  but  because  the  time  was 


CELLS  OF  BODY  AND  INVADING  CELLS  5 

unpropitious  the  voices  of  these  pioneers  had  fallen  on  deaf  ears, 
and  to  Joseph  Lister  was  to  belong  the  honor  of  leading  the  way 
in  the  greatest  forward  step  that  had  been  made  since  surgery 
began. 

The  early  investigations  of  Pasteur  had  shown  that  the 
familiar  phenomena  of  fermentation  and  putrefaction  were  in 
reality  due  to  the  action  of  minute  living  organisms  which  the 
microscope  had  made  visible,  and  the  character  of  the  foul  dis- 
charges from  inflamed  wounds,  so  like  the  putrefactive  process, 
suggested  to  Lister  the  possibility  of  a  similar  causation.  The 
case  as  regards  fractures  was  particularly  suggestive  of  this.  It 
was  a  commonplace  that  simple  fractures,  i.e.,  where  the  skin 
was  unbroken,  healed  without  inflammation,  fever  or  any  foul 
discharge,  and  practically  all  these  cases  recovered.  In  compound 
fractures,  on  the  other  hand,  i.e.,  where  an  open  wound  communi- 
cated with 'the  broken  bones,  the  putrefaction-like  process  of 
suppuration  accompanied  with  inflammation  and  fever  invariably 
occurred,  and  the  majority  of  these  patients  died.  In  Lister's 
mind  it  was  a  clear  inference  that  the  difference  in  these  two  cases 
was  due  to  the  entrance  into  the  wound  of  living  germs  from  the 
air,  and  he  acted  on  this  idea.  Carbolic  acid  was  already  known 
as  an  efficient  preventive  of  putrefaction,  and  in  August,  1865, 
Lister  first  applied  a  carbolic  dressing  to  the  wound  of  a  compound 
fracture.  The  result  was  all  that  he  had  hoped.  No  suppuration 
occurred.  A  scab  formed  over  the  wound  and  the  case  progressed 
to  recovery  like  a  simple  fracture.  Other  similar  results  followed, 
and  he  was  encouraged  to  extend  the  application  of  what  he 
called  "the  antiseptic  principle  in  surgery"  to  other  accidental 
wounds  and  also  to  operative  wounds  with  equal  success.  Still 
possessed  by  the  natural  but  mistaken  idea  that  the  air  was  the 
source  from  which  the  dangerous  organisms  came,  he  began  to 
perform  his  operations  under  a  cloud  of  spray  impregnated  with 
carbolic  vapor  formed  by  a  steam  nebulizer.  Instruments  were 
smeared  with  carbolic  oil,  hands,  sponges,  ligatures  and  dressings 
dipped  into  carbolic  solution.  These  methods  were  crude  in  the 
light  of  later  developments,  but  they  sufficed. 

The  new  principle  in  surgery  thus  inaugurated  was  naturally 
not  accepted  all  at  once  or  without  controversy,  but  Lister's 
mind  was  of  too  fine  a  temper  to  be  discouraged  by  opposition 
or  embittered  by  hostile  criticism.  He  pressed  on,  constantly 
improving  his  methods,  and  his  results  soon  accumulated  a  weight 


6  INFECTION 

of  evidence  that  compelled  recognition  from  his  doubting  col- 
leagues. But  while  better  healing  of  wounds  under  the  new 
method  was  too  obvious  to  be  denied,  yet  further  proof  was 
needed  that  living  organisms  were  in  truth  the  cause  of  suppu- 
ration, and  a  long  and  at  times  bitter  controversy  followed. 

While  Lister  and  his  followers  were  gaining  their  brilliant 
results  the  laboratory  workers  were  making  new  discoveries. 
Little  by  little  vague  ideas  gave  place  to  exact  knowledge,  until 
what  was  first  called  the  "germ  theory"  of  disease  was  finally 
advanced  to  the  status  of  a  scientific  demonstration.  Robert 
Koch,  who  began  his  studies  while  a  country  practitioner  in  Ger- 
many, devised  a  method  by  which  individual  organisms  could 
be  separated  and  made  to  propagate  in  culture  media,  making 
it  easy  to  study  the  different  species  of  bacteria  in  pure  culture, 
thus  opening  the  way  for  the  rapid  advancement  of  our  knowledge 
of  the  life  history  of  these  organisms  and  their  relation  to  disease. 
Pasteur,  who  heard  of  Lister's  work  with  the  liveliest  interest, 
was  the  first  to  isolate  and  study  the  two  species  of  living  germs 
which  surpass  in  frequency  all  others  concerned  in  the  infection 
of  wounds.  One  he  found  in  a  series  of  boils,  from  which  an  as- 
sistant in  the  laboratory  was  suffering;  the  other  in  the  lochia 
from  a  case  of  puerperal  fever.  The  scourge  of  infection  among 
women  in  childbirth  was  not  less  appalling  at  that  time  than  in 
the  surgical  hospital  wards.  Deaths  from  puerperal  fever  rose 
at  times  as  high  as  one  in  six,  of  women  in  confinement.  A  dra- 
matic incident  is  related  of  Pasteur,  who  was  present  at  a  meet- 
ing where  a  celebrated  surgeon  was  speaking  on  the  causes  of 
puerperal  fever.  Pasteur  rose  in  his  place  in  the  audience. 
"The  cause  is  no  such  thing,"  he  said,  "It  is  a  germ,  and  is  con- 
veyed by  the  surgeon  and  attendants  from  a  sick  woman  to  a 
well  one. "  The  lecturer  sarcastically  replied  that  if  such  a  germ 
existed  he  was  well  assured  it  would  never  be  seen.  Pasteur 
stepped  to  the  blackboard  and  drew  a  number  of  minute  spheres 
arranged  like  a  string  of  beads  (see  Fig.  16).  "I  have  seen  it," 
he  declared,  "  and  that  is  its  picture. " 

The  methods  of  wound  treatment  and  the  technic  at  opera- 
tions designed  to  prevent  infection,  which  Lister's  earlier  experi- 
ments introduced,  were  crude  indeed  compared  with  those  in  use 
at  the  present  time,  but  while  nature  holds  us  to  strict  account 
for  disobedience  to  her  laws  she  often  rewards  us  generously, 


CELLS  OF  BODY  AND  INVADING  CELLS  7 

even  lavishly,  for  only  a  partial  understanding  of  her  secrets. 
It  was  so  now.  As  Lister's  methods  began  to  come  into  general 
use  suppuration  in  wounds  became  less  and  less  frequent.  Large 
mortalities  dropped  to  small  and  in  some  cases  even  to  negligible 
figures.  Healing  "by  first  intention,"  so-called  from  the  time  of 
Hippocrates,  i.e.,  healing  without  inflammation  or  suppuration, 
ceased  to  be  a  surgical  curiosity  and  began  to  be  called  normal 
healing.  The  awful  scourge  of  hospital  gangrene,  so  common  up 
to  Lister's  time,  vanished  utterly. 

The  result  of  Lister's  work  for  surgery  may  be  likened  to 
the  setting  free  of  a  lifelong  captive  from  a  dark  and  narrow 
prison.  The  strong  doors,  barred  and  guarded  for  so  many  ages, 
were  now,  almost  suddenly,  thrown  wide  open.  Surgeons,  grop- 
ing forward  in  an  unaccustomed  freedom,  many  of  them  hardly 
realizing  what  had  happened,  began  to  find  that  they  could  now 
do  many  things  safely  that  had  always  been  prohibited.  Con- 
stant improvements  in  technic  opened  the  way  for  new  suc- 
cesses. The  gradual  recognition  of  the  fact  that  the  entrance 
of  bacteria  into  wounds  occurs  practically  always  by  contact 
with  material  things  to  which  these  organisms  adhere  (hands, 
instruments,  ligatures,  dressings),  while  infection  through  the  air 
is  negligible;  the  introduction,  first  in  Koch's  laboratory,  of 
sterilization  by  high -pressure  steam;  and  the  use  of  rubber  gloves 
for  the  hands  of  the  surgeon  and  his  assistants,  first  practised 
by  Halsted  at  the  Johns  Hopkins  Hospital,  revolutionized  the 
earlier  methods  of  preventing  inlet -(ion  in  operative  wounds, 
inaugurating  the  present  or  what  is  known  as  the  " aseptic"  era, 
in  contradistinction  to  the  "antiseptic"  era  of  early  Listerian 
practice,  and  enabled  surgeons  to  perform  the  most  extensive 
operations  in  all  the  formerly  forbidden  regions  of  the  body  with 
an  almost  mathematical  certainty  that  no  infection  would  follow 
and  that  normal  healing  would  be  secured.  The  way  was  thus 
opened  for  the  immense  development  of  operative  surgery  which 
in  the  past  fifty  years  has  been  many  times  greater  than  in  all 
the  preceding  centuries.  There  were  many  new  difficulties  to 
be  overcome  and  dangers  to  be  encountered,  but  the  difference 
was  that  under  the  old  conditions  these  problems  could  not  be 
approached  at  all;  now  the  path  was  clear. 

Among  the  many  changes  which  the  new  era,  resulting  from 
these  discoveries,  lias  brought  about,  not  the  least  in  importance 
is  concerned  with  surgical  nursing.  The  time  has  long  passed 


8  INFECTION 

when  a  surgical  operation  was  the  work  of  one  man  with  the 
assistance  of  one  or  two  unskilled  helpers.  Success  under  modern 
conditions  requires  the  coordinated  efforts  of  a  highly  trained 
and  perfectly  organized  team  of  workers.  The  aseptic  surgical 
technic,  that  elaborate  system  which  has  been  gradually  worked 
out,  whose  object  is  to  prevent  the  occurrence  of  infection  in 
wounds,  demands  not  only  the  strict  observance  of  proper 
methods  at  the  operation  itself,  but  also  expert  knowledge  and 
conscientious  exactness  in  all  the  details  of  preparation.  This 
work  of  preparation  calls  for  its  own  separate  organization,  with 
an  elaborate  equipment  of  technical  apparatus  requiring  special 
skill  in  its  use,  and  the  responsibility  for  this  rests  almost  wholly 
upon  the  shoulders  of  the  surgical  nurse.  It  is  highly  important 
that  the  carrying  out  of  this  part  of  the  work  should  depend, 
not  upon  the  blind  observance  of  a  set  of  rules,  vaguely  under- 
stood and  often  imperfectly  remembered,  but  rather  upon  an 
intelligent  application  of  clearly  comprehended  principles,  based 
upon  a  correct  knowledge  of  the  conditions  under  which  wound 
infection  takes  place.  Before  entering,  therefore,  upon  the  prac- 
tical side  of  our  presentation  of  the  technical  duties  involved  in 
surgical  and  gynaecological  nursing,  it  is  necessary  to  devote  some 
space  to  a  consideration  of  the  infection  problem,  the  life  history 
and  distribution  of  the  living  organisms  concerned,  and  the 
relation  of  these  organisms  to  infectious  disease. 

I.  THE  CELL 

1.  The  Cell  as  the  Unit  of  Living  Matter.— To  understand 
the  meaning  of  infection  we  must  begin  with  the  study  of  the 
cell.  When  plant  tissues  were  first  examined  under  the  micro- 
scope they  appeared  to  be  made  up  of  an  aggregation  of  tiny 
hollow  chambers,  which,  because  of  their  likeness  to  the  structure 
of  a  honey-comb,  were  called  cells.  When  on  later  study  it 
became  gradually  clear  that  all  living  matter  is  made  up  of  very 
small  individual  structural  units,  the  name  "cell"  was  retained 
for  these  units,  although  in  most  cases  they  bear  no  resemblance 
to  a  hollow  chamber.  Every  living  thing,  whether  plant  or 
animal,  is  composed  of  cells.  The  bodies  of  all  the  higher  animals, 
man  included,  are  built  up  out  of  a  vast  number  of  cells  of  many 
kinds,  and  all  the  activities  of  their  bodies,  of  growth,  of  nutrition, 
of  secretion,  of  movement,  or  of  reproduction,  are  really  the 
activities  of  the  cells  which  compose  them. 


CELLS  OF  BODY  AND  INVADING  CELLS 


9 


2.  Form  and  Structure  of  the  Cell. — Cells  exhibit  immense 
variety  in  size,  in  form,  in  structural  complexity,  and  particularly 
in  functional  activity.  A  few  may  be  large  enough  to  be  visible 
to  the  naked  eye,  but  most  are  far  too  small  to  be  seen  without 
the  aid  of  magnifying  lenses.  In  its  essential  features  a  cell 
(Fig.  1)  consists  of  a  minute  globule  of  matter,  the  cell  body, 
containing  in  its  centre  a  smaller  body  called  the  nucleus.  A 
more  or  less  clearly  defined  membrane,  the  cell  wall,  may  sur- 
round the  body  of  the  cell.  When  a  cell  is  stained  with  aniline 
dyes  the  nucleus  takes  the  stain  more  strongly  than  the  cell 


Cell  wall  or  limiting 
membrane 


Nuclear  membrane 


Nucleus 


Cell  substance  or 
cytoplasm 


FIG.  1. — Diagram  of  a  cell. 

body  and  appears  clearly  and  sharply  defined,  demonstrating 
its  difference  in  chemical  composition  from  the  remaining  cell 
substance.  The  nucleus  is  believed  to  be  the  most  important 
element  in  the  cell  structure.  It  contains  a  special  substance, 
peculiar  to  living  matter,  known  as  "chromatin"  or  "chromo- 
plasm,"  which  appears  to  play  the  most  important  role  in  the 
cell  activities.  The  substance  of  the  cell  body  is  called  "  cyto- 
plasm." It  may  be  smooth  or  granular  in  appearance,  and  some- 
times has  the  suggestion  of  an  intracellular  network.  The  con- 
sistence of  the  cell  substance  is  probably  that  of  a  semifluid  or 
thin  jelly.  The  solid  part  of  plants  and  animal  bodies  are  not 
generally  regarded  as  part  of  the  living  cell  substance,  but  as 
inert  material  built  up  by  the  chemical  activities  of  the  cell. 
Many  cells,  particularly  among  the  single-celled  organisms,  have 


10 


INFECTION 


special  structural  appendages  to  facilitate  their  motion  or  for 
other  uses. 

3.  The  Activities  of  the  Cell:  (1)  Movement. — Many  cells 
have  the  power  of  motion  by  virtue  of  a  contraction  of  a  portion 
of  the  cell  substance  in  various  ways.  The  movements  of  single- 
celled  organisms  and  the  muscular  movements  of  the  higher 
animals  are  alike  due  to  the  exercise  of  this  power. 

(2)  Reproduction. — At  some  period  in  its  life  every  cell  has 
the  power  of  reproduction  by  dividing  itself,  usually  into  two 
daughter  cells  (Fig.  2),  sometimes  into  many  new  cells.  Over 
this  process  the  nucleus  presides  through  a  series  of  wonderfully 


FIG.  2. — -Multiplication  by  simple  division  in  Entamceba  coli  (Craig).    This  is  a  single- 
celled  organism  which  is  the  cause  of  certain  forms  of  tropical  dysentery  in  man. 

complex  changes.  Every  existing  cell  has  arisen  from  another 
cell  through  the  exercise  of  this  reproductive  power.  Each  cell 
reproduces  only  its  own  kind. 

(3)  Chemical  Activities. — All  cell  activities  are  doubtless 
chemical  in  nature,  but  the  mature  cell  does  a  vast  amount  of 
work  in  changing  the  chemical  composition  of  substances  taken 
into  its  own  body  and  of  the  material  surrounding  it.  These 
chemical  activities  appear  in:  (a)  the  absorption  of  suitable 
material  from  their  surroundings  to  be  utilized  in  their  nutrition 
and  growth ;  (6)  in  oxidation,  or  the  burning  up  of  material  with 
the  production  of  heat;  (c)  secretion,  or  the  formation  of  new 
chemical  compounds  which  are  then  extruded  from  the  cell; 
(d)  excretion,  the  casting  off  of  waste  material;  and  (e)  what  is 
perhaps  akin  to  secretion,  the  building  up  of  intercellular  sub- 
stances which  form  the  solid  parts  of  the  structure  of  animals 
and  plants. 

4.  The  Vital  Requirements  of  the  Cell:  (1)  Moisture.— 
Every  living  cell  must  be  surrounded  with  moisture  in  order  to 


CELLS  OF  BODY  AND  INVADING  CELLS  11 

enable  it  to  carry  on  its  chemical  activities.  All  the  living  cells 
of  the  human  body  are  bathed  in  fluid.  A  scratch  upon  the 
surface  shows  how  thin  is  the  protecting  covering  of  inert  dried 
material  by  which  the  fluids  are  confined.  Matter  upon  which 
the  cell  acts  to  produce  chemical  change  must  first  be  brought 
into  a  state  of  solution,  and  a  fluid  environment  is  therefore 
necessary  to  all  cell  life. 

(2)  Food. — Cells  require  suitable  material  in  their  surround- 
ings to  be  utilized  by  them  for  their  nutrition  and  growth  and 
for  the  exercise  of  their  other  chemical  activities.     Some  cells 
can  go  into  a  resting  stage,  during  which  they  remain  alive, 
although  deprived  for  the  time  of  food  and  of  moisture.    Later, 
under  favorable  conditions  of  moisture,  food  supply,  and  tem- 
perature, they  may  renew  their  active  life. 

(3)  Temperature. — Active  cell    life    is   possible  only  within 
rather  narrow  limits  of  heat  and  cold.     For  each  kind  of  cell 
there  is  an  " optimum"  temperature  at  which  it  thrives  best. 
At  a  temperature  a  few  degrees  below  this  all  cell  activity  will 
be   checked   or   cease   entirely.      At   a   temperature   somewhat 
higher  the  life  of  the  cell  will  be  destroyed.     Some  cells  in  a 
resting  stage  (such  as  the  spores  of  certain  bacteria)  can  survive 
extreme  degrees  of  heat,  considerably  above  the  boiling  point 
of  water.    Most  cells  bear  exposure  to  cold  rather  well.    Many  of 
the  cellsof  our  own  bodies  can  recover  froma  freezing  temperature. 

5.  The  Characteristics  or  Qualities  of  the  Cell:  (1)  Irrita- 
bility.— This  means  that  the  activity  of  a  cell  can  be  affected 
by  influences  from  without.  Any  influence  exerted  upon  a  cell 
which  causes  a  change  in  its  activities  is  called  a  " stimulus." 
All  the  activities  of  a  cell  may  be  affected  by  a  stimulus — its 
nutrition,  its  secretions,  its  motion,  or  its  reproductive  power; 
and  the  effect  of  the  stimulus  may  be  manifested  in  either  of 
two  ways,  by  increasing  or  by  diminishing  the  activity  of  the 
cell,  or,  as  we  say,  the  effect  may  be  to  excite  or  to  inhibit  its 
activities.  Any  external  changing  condition  may  act  as  a  stimu- 
lus— mechanical  or  chemical  effects,  light,  heat,  electricity,  the 
influence  which  nerve  fibres  convey,  and  so  on.  Certain  condi- 
tions within  the  body  of  the  cell  itself  may  also  act  as  stimuli, 
such,  for  example,  as  its  own  physiological  condition,  particularly 
with  regard  to  its  supply  of  nourishment.  Thus  starvation  or 
repletion  will  affect  its  activities  in  different  ways.  The  excited 
activity  may  continue  for  a  time  after  the  stimulus  has  ceased 


12  INFECTION 

to  act.  Repeated  stimulation  may  bring  about  exhaustion  and 
cessation  of  activity.  Repeated  stimulation,  not  of  too  high 
intensity  or  too  continuous,  may  develop  and  increase  the  cell's 
power  of  action  in  some  one  direction.  A  high  intensity  may 
inhibit,  while  a  lower  intensity  of  the  same  stimulus  may  excite 
cell  activity.  When  a  cell's  activity  is  affected  by  a  stimulus 
it  is  said  to  respond  or  react  to  the  stimulus.  The  lowest  intensity 
of  a  stimulus  which  will  cause  a  cell  to  react  is  called  the  "thresh- 
old" for  that  stimulus.  Repeated  stimulation  may  result  in 
some  cases  in  cessation  of  response  on  the  part  of  the  cell  or  a 
raising  of  the  threshold,  a  higher  intensity  being  required  to 
excite  action.  The  sum  total  of  all  the  stimuli  acting  on  a  cell 
constitute  its  " environment." 

(2)  Adaptability. — That  quality  of  the  cell  whereby  it    is 
enabled  to  respond  differently  to  a  stimulus  because  of  previous 
stimulation  is  of  far-reaching  significance  in  the  economy  of 
nature.    Because  of  this  the  cell  is  enabled  to  adapt  itself  within 
certain  limits  to  changed  conditions  in  its  environment.     The 
capacity  of  the  cell  to  increase  its  power  under  stimulation  is 
also  a  factor  in  the  adaptation  of  the  individual  cell  to  changed 
conditions.    Moreover,  there  are  always  slight  differences  among 
individual  cells  of  the  same  kind  in  regard  to  their  susceptibility 
to  certain  influences.     Under  changed  conditions,  then,  some 
cells  may  perish  while  others  survive,  and  these  may  transmit 
their  resisting  powers  to  their  descendants,   giving  rise  to  a 
strain  adapted  to  the  new  environment. 

(3)  Specialization. — In  the  single-celled  organisms  and  in  the 
cells  which  make  up  the  tissues  of  animals  and  plants  there  is 
an  infinite  variety  in  the  forms  of  activity  which  the  cells  exhibit. 
No  cell  is  capable  of  all  the  forms  of  activity  possible  for  a  cell, 
but  each  kind  of  cell  specializes  in  some  particular  form.    Cells 
are  specialized  not  only  in  their  activities  but  also  in  being 
adapted  to  respond  to  particular  kinds  of  stimuli.     Thus,  for 
example,  certain  cells  in  the  retina  of  the  eye  are  specially  adapted 
to  respond  to  light,  other  cells  in  the  ear  to  respond  to  vibrations 
in  the  air.    Any  stimulus  capable  of  exciting  the  special  activity 
of  a  cell  is  called  an  adequate  stimulus  for  that  cell.    A  specialized 
cell  responds  with  its  own  particular  form  of  activity  whatever 
the  nature  of  the  stimulus. 

(4)  Constant  Change. — The   chemical   changes  which  go  on 
within  the  living  cell  are  exceedingly  complex.    It  is  a  chemistry 


CELLS  OF  BODY  AND  INVADING  CELLS  13 

of  constant  giving  up  and  taking  in,  special  substances  capable 
of  serving  a  purpose  useful  to  the  organism  are  formed,  and  other 
substances  are  thrown  out  because  they  have  served  their  purpose 
and  become  waste  matter.  New  matter  is  meanwhile  being 
taken  in  to  be  built  up  into  living  substance  in  place  of  the 
material  that  has  been  thrown  out.  The  cell  is  thus  ceaselessly 
falling  to  pieces  and  rebuilding  its  own  substance. 

(5)  Continuity  of  Life. — In  the  process  of  reproduction  the 
cell  does  not  die,  but  passes  on  its  own  substance  and  its  living 
activities  into  two  or  more  daughter  cells.    Thus  cell  life  is  con- 
tinuous and  not  interrupted  by  any  condition  that  can  be  called 
death.    Many  cells  are  destroyed,  of  course,  by  accident  or  other- 
wise; and  many  differentiated  cells,  having  lost  the  power  of 
reproduction,  perish  when  their  usefulness  is  ended,  but  there 
is  a  sense  in  which  it  may  be  said  that  death  has  no  meaning  as 
applied  to  the  cell. 

(6)  Stability. — The  evidences  of  life  upon  the  earth  in  remote 
geologic  ages,  in  all  essentials  like  the  forms  of  life  now  existing, 
give  striking  proof  of  the  immense  stability  of  the  hereditary 
factors  in  the  reproduction  of  the  cell,  while  the  traces  of  a 
wonderful   evolutionary   history  throughout  these  ages  testify 
with  equal  force  to  its  powers  of  adaptation. 

For  the  solution  of  all  the  problems  in  every  department  of 
science  relating  to  living  things  we  must  seek  the  final  answer 
in  the  study  of  these  tiny  units  in  the  structure  of  all  living 
things.  Incessantly  disintegrating,  yet  immortal;  more  stable 
than  continents  and  oceans,  yet  infinitely  plastic  and  adaptable; 
the  cell,  which  is  the  ultimate  unit  of  living  matter,  serves  also 
as  the  most  fitting  symbol  and  expression  of  the  mystery  of  life. 

II.  SINGLE-CELLED  ORGANISMS 

By  the  term  organism  is  meant  any  individual  animal  or 
plant  which  lives  a  self-sufficient  existence  and  in  due  course 
reproduces  its  own  kind.  Among  the  lower  forms  of  life  there 
are  very  many  organisms  which  consist  of  only  a  single  cell. 

These  single-celled  or  unicellular  organisms  behave  in  a 
primitive  way  much  like  the  higher  forms.  Each  cell  lives  an 
independent  existence.  They  assimilate  nourishment,  grow,  and 
reproduce  their  kind;  and  many  of  them  are  able  to  move  about 
by  means  of  active  movements  of  portions  of  the  cell  body,  or 
through  special  organs  of  locomotion,  usually  by  a  swimming 


14  INFECTION 

process,  for  like  all  cells  they  require  fluid  surroundings  for  their 
active  life. 

Unicellular  organisms  are  very  abundantly  distributed  in 
nature.  A  vast  number  of  different  species  of  them  exist,  differing 
widely  in  structure,  in  their  activities,  and  in  the  conditions 
under  which  they  thrive.  Swarming  in  countless  numbers  and 
variety  wherever  the  conditions  are  favorable  for  them — in 
water,  in  soil,  as  parasites  living  upon  higher  organisms,  and 
especially  wherever  there  is  dead  organic  matter — these  silent, 
invisible  living  things  play  a  role  of  incalculable  magnitude  and 
importance  in  the  happenings  of  our  world. 

III.  MANY-CELLED  ORGANISMS 

There  are  no  two-,  or  three-,  or  few-celled  organisms.  We  pass 
at  once  from  the  single-celled  forms  to  those  that  are  composed 
of  many  cells.  These  include  many  forms  that  are  very  low  in 
the  scale,  and  also,  of  course,  all  the  higher  species  of  plants  and 
animals.  In  the  multicellular  organisms  the  cells  do  not  live  a 
separate  and  self-sufficient  existence.  They  are  dependent  on 
each  other  for  many  of  their  needs,  and  their  activities  are  often 
directed  for  the  benefit  of  the  organism  as  a  whole  rather  than 
solely  for  their  own  individual  requirements. 

The  most  striking  feature  of  the  higher  forms  of  life,  con- 
sidered as  an  aggregation  of  cells,  is  the  amazingly  perfect  organ- 
ization which  they  exhibit.  This  organization  is  manifest  both 
in  structure  and  in  function.  On  the  structural  side  we  have  the 
differentiation  of  cells  into  peculiar  tissues  and  the  aggregation 
of  similar  cells  into  special  organs.  In  the  animal  body  there  are 
complex  structures  for  locomotion,  for  the  seizing  of  food  material 
and  for  its  digestion,  and  others  for  the  purpose  of  keeping  all 
the  cells  bathed  in  fluid  and  for  conveying  to  them  the  nourish- 
ment that  has  been  prepared  for  them.  There  are  other  organs 
(the  special  senses)  for  the  reception  of  stimuli  from  outside  the 
body,  so  that  the  behavior  of  the  animal  can  be  modified  in  ways 
appropriate  to  its  environment.  As  regards  organization  in 
function  we  have  a  nearly  perfect  system  of  control  whereby 
all  the  cell  activities  of  the  body  are  directed  for  the  benefit 
of  the  whole  organism. 

It  is  the  capacity  of  the  cell  to  respond  to  a  stimulus  which 
makes  it  possible  for  the  higher  living  organisms  to  exist,  since 
because  of  it  the  cells  composing  the  organism  can  be  made  to 


CELLS  OF  BODY  AND  INVADING  CELLS  15 

act  in  harmony.  Our  own  bodies,  for  example,  are  made  up  of 
an  innumerable  host  of  cells  whose  activities  are  not  haphazard 
or  independent,  but  are  obviously  marshalled  under  orderly 
control  and  discipline.  A  wonderful  division  of  labor  exists 
among  them.  The  muscle  cells  have  given  up  all  their  other 
activities,  save  nutrition,  to  devote  their  whole  energy  to  the 
exercise  of  their  contractile  power.  Epithelial  cells  cover  the  body 
surfaces  and  line  the  tubes  and  ducts  of  the  various  secreting 
glands  where  they  specialize  in  the  production  of  different  secre- 
tions which  are  useful  to  the  organism  as  a  whole.  The  connec- 
tive tissue  cells,  through  thickening  of  the  cell  wall  and  the 
formation  of  intercellular  substances,  build  up  the  supporting 
framework  of  the  body,  its  bones,  ligaments,  tendons,  etc.  The 
nerve-cells  are  organized  into  a  wonderfully  complex  system  for 
the  regulation  of  all  the  bodily  functions  and  activities.  They 
specialize  in  the  reception  and  coordination  of  stimuli  received 
from  sources  external  to  the  body,  and  in  the  conveying  of  appro- 
priate stimuli  to  the  cells  of  the  various  organs  so  that  they  may 
act  in  harmony  for  the  best  interests  of  the  organism  as  a  whole. 

All  the  structural  features  of  the  body,  its  framework,  its 
coverings  of  skin  and  mucous  membranes,  its  complex  tissues 
and  organs,  and  all  their  manifold  functional  activities,  are  thus 
the  result  of  the  work  of  specialized  cells  under  a  marvellously 
complex  system  of  control. 

We  do  not  know  what  the  factors  are  that  determine  this 
organization.  But  it  is  quite  certain  that  the  amount  or  the 
intensity  of  the  various  activities  of  any  cell  is  determined  by  the 
stimuli  arising  from  its  environment,  and  in  the  animal  body,  for 
example,  a  large  part  of  this  environment  consists  of  conditions 
resulting  from  the  activities  of  other  cells,  so  that  there  is  an 
amazingly  intricate  interplay  of  stimuli  between  the  different 
cells  of  the  organism.  There  are  also  adjustments  for  the  rapid 
conveyance  of  stimuli  arising  from  the  activities  of  one  set  of 
cells  to  other  cells  at  a  distance,  largely  through  the  nervous 
system,  but  partly  also  by  other  means.  Thus  the  responses  of 
the  cells  to  external  stimuli,  to  stimuli  arising  from  their  own 
physiological  condition,  and  to  stimuli  arising  from  the  activities 
of  other  cells,  bring  about  as  a  resultant  an  orderly  balance  and 
harmony  in  the  activities  of  all  the  cells,  and  a  condition  of  the 
body  as  a  whole  which  we  designate  as  normal  or  as  a  condition 
of  health. 


16  INFECTION 


IV.  HEALTH  AND  DISEASE 

The  word  " normal"  means  conforming  to  a  recognized  stand- 
ard; agreeing  with  an  established  type,  but  the  standard  is  never 
very  exact.  Thus  in  any  group  of  persons  each  one  may  be  a 
normal  individual  although  differing  rather  widely  in  many  par- 
ticulars from  others  in  the  group.  The  same  is  true  of  the  normal 
working  of  a  many-celled  organism  as  represented  by  the  har- 
monious activities  of  its  cellular  elements.  The  normal  standard 
for  these  multitudinous  activities  is  not  rigid  but  extremely 
flexible.  A  deficiency,  whether  momentary  or  continued,  of  one 
part  of  the  mechanism  may  be  supplemented  or  compensated  for 
in  various  ways  by  increased  activity  in  other  parts.  Thus  an 
adjustment  of  the  working  of  the  complex  organism  to  changing 
conditions  in  its  environment  is  continually  going  on.  Different 
kinds  or  groups  of  cells  are  inevitably  subjected  from  time  to 
time  to  alien  stimuli,  often  in  themselves  potentially  harmful, 
and  in  such  a  case  the  organism  must  automatically  find  an  answer 
to  the  problem  of  adjusting  itself  to  that  particular  situation. 
This  adjustment  of  the  organism  to  its  environment  is  called 
"  adaptation."  It  is  a  commonplace  that  different  living  organ- 
isms are  adapted  to  exist  in  very  various  surroundings;  some,  for 
example,  to  live  under  water,  others  on  land.  Moreover,  each 
individual  of  a  species  has  inherited  the  power  of  calling  into  play 
innumerable  and  often  extremely  dexterous  ways  of  adjusting  or 
adapting  itself  to  harmful  situations,  When  these  adaptations 
are  very  perfect  so  that  the  organism  is  able  to  meet  the  situation 
with  little  or  no  disturbance  of  its  functions  we  may  consider 
the  resulting  adjustment  as  a  normal  condition.  When,  on  the 
other  hand,  the  adaptation  is  more  or  less  imperfect,  an  abnormal 
or  diseased  condition  will  be  brought  about.  For  example,  when 
any  tissue  of  the  human  body  has  been  subjected  to  a  direct 
mechanical  injury,  e.g.,  a  wound,  there  results  an  adjustment  of 
the  cell  activities  which  we  call  the  healing  process.  This  adjust^ 
ment  while  not  ideally  perfect  is  in  a  very  high  degree  efficient, 
and  when  not  interfered  with  in  any  way  proceeds  to  repair  the 
defect  with  such  smoothness,  certainty,  .and  speed  and  with  so 
little  disturbance  of  the  organism  as  a  whole  that  we  are  nearly 
or  quite  justified  in  calling  it  a  normal  process,  although  the  cell 
activities  involved  are  quite  different  from  those  exercised  in 
ordinary  times.  Surgery  is  wholly  dependent  upon  this  nearly 


CELLS  OF  BODY  AND  INVADING  CELLS  17 

perfect  adaptation,  for  without  it  surgery  would  be  impossible, 
and  the  fundamental  problems  of  practical  surgery  are  concerned 
with  the  selection  of  methods  for  attaining  the  end  desired  which 
shall  place  the  smallest  possible  obstacles  in  the  path  of  the  heal- 
ing process.  On  the  other  hand,  from  what  has  already  been 
said  at  the  beginning  of  this  chapter  it  is  quite  evident  that 
when  a  wound  is  infected  the  healing  process  is  very  seriously 
interfered  with.  A  new  situation  is  developed  to  meet  which 
the  organism  is  very  imperfectly  adapted,  and  the  condition 
which  results  cannot  be  called  normal,  but  must  be  regarded  as 
one  of  disease.  There  is  thus  no  hard  and  fast  line  between  the 
normal  and  the  abnormal,  i.e.,  between  health  and  disease. 
Disease  may  be  said  to  be  present  when  as  the  result  of  an  imper- 
fect adaptation  to  an  injurious  influence  the  normal  balance  of 
the  activities  of  the  body -cells  is  destroyed. 

V.  INFECTION 

Now  one  of  the  most  potent  and  also  one  of  the  most  common 
causes  of  disease — that  is  to  say,  of  such  a  disturbance  of  the 
disciplined  harmony  in  the  activities  of  the  cells  of  the  organism 
— consists  in  the  entrance,  among  the  cells  of  the  body,  of  other 
cells  which  invade  it  from  the  outer  world.  When  such  alien 
and  hostile  cells,  not  subject  to  the  discipline  of  its  controlling 
system,  obtain  entrance  into  the  body  and  find  in  any  of  its 
tissues  a  situation  and  surroundings  suitable  for  their  growth, 
they  multiply  there,  and  by  their  growth  and  the  secretions 
which  they  produce  they  cause  either  a  destruction  of  the  body- 
cells  or  an  interference  with  their  normal  working.  This  invasion 
of  alien  cells  harmful  to  the  body  we  speak  of  as  an  " infection," 
and  the  effects  in  the  body  of  their  harmful  activities  we  call  an 
infectious  disease. 

All  of  the  large  and  familiar  class  of  infectious  diseases  are 
caused  by  the  entrance  among  the  body-cells  of  unicellular 
organisms  from  without.  It  must  not  be  supposed,  however, 
that  all  the  unicellular  organisms  can  thus  invade  the  body.  On 
the  contrary,  the  vast  majority  of  these  organisms,  which  exist 
in  such  countless  numbers  all  about  us,  find  in  the  tissues  of 
the  animal  body  conditions  altogether  unfavorable  for  them, 
and  they  can  no  more  live  there  than  a  fish  can  live  out  of  water 
or  an  air-breathing  animal  can  live  under  the  sea.  Unfortunately 
for  us,  however,  there  are  certain  species  of  microorganisms 
2 


18  INFECTION 

which  are  specially  adapted  to  live  and  multiply  within  the 
tissues  of  our  bodies.  Fortunately  for  us,  on  the  other  hand, 
these  species  are  relatively  few. 

There  are  certain  species  of  the  hostile  invaders  which  grow 
readily  in  any  tissue  of  the  body  where  an  injury  has  taken 
place.  An  open  wound  offers  an  ideal  portal  of  entrance  for  them 
and  the  injured  tissues  a  favorable  soil  for  their  growth. 

Infection  through  a  wound  with  these  particular  species  of 
alien  cells  we  speak  of  as  " septic"  infection,  and  the  resulting 
disease  affecting  the  wound  and  the  body  as  a  whole  is  known 
as  "sepsis,"  "septicaemia,"  or  "septicopysemia." 

VI.  THE  SINGLE-CELLED  ORGANISMS  CONCERNED  IN 
INFECTION 

1.  Bacteria. — Among  the  microorganisms  which  play  the 
part  of  hostile  invaders  among  the  body-cells,  the  bacteria  are 
the  most  numerous  and  important  class.  All  the  organisms  con- 
cerned in  wound  infections  belong  to  the  bacteria.  The  bacterial 
cell  is  characterized  by  extremely  minute  size,  great  simplicity 
in  form,  and  apparent  simplicity  in  structure  and  manner  of 
reproduction.  On  the  other  hand,  the  greatest  variety  and  com- 
plexity is  shown  in  the  character  of  the  cell  activities,  i.e.,  in 
the  chemical  composition  of  the  secretions  which  the  cells  pro- 
duce and  in  the  different  conditions  under  which  they  thrive. 
An  immense  number  of  distinct  species  can  be  recognized  mainly 
by  these  differences  in  vital  activities,  the  form  differences  being 
relatively  insignificant  or  even  in  some  cases  indistinguishable. 
The  cell  is  many  times  smaller  than  the  average  size  of  the  cells 
which  make  up  the  structure  of  animals  and  plants  (Fig.  3). 
Bacteria  are  either  rod-shaped  or  spherical  in  form.  Straight 
rods  are  called  bacilli  (Fig.  4) ,  rods  with  a  slight  curve  are  known 
as  spirilla  (Fig.  5).  The  rods  vary  considerably  in  length  and 
thickness  and  may  have  rounded  or  blunt  ends.  Bacilli  are  either 
motile  or  non-motile,  the  former  possessing  whip-lash-like  append- 
ages, attached  sometimes  to  the  ends,  sometimes  to  all  sides, 
which  by  their  rapid  vibration  propel  the  organism  through  the 
surrounding  fluid  (Fig.  6).  The  spherical  forms,  known  as  micro- 
cocci,  differ  only  slightly  in  size,  but  characteristic  differences 
in  grouping  appear,  those  which  are  seen  in  pairs  being  known 
as  diplococci  (Fig.  7),  others  which  appear  in  chains,  like  a  string 
of  beads,  are  called  streptococci  (Fig.  8),  while  staphylococci 


CELLS  OF  BODY  AND  INVADING  CELLS  19 

(Fig.  9)  show  an  arrangement  in  irregular  bunches.  Reproduc- 
tion takes  place  by  simple  division.  A  fissure  appears  in  the 
centre  of  the  bacillus  or  the  micrococcus,  which  presently  sepa- 
rates it  into  two  equal  parts.  Each  half  grows  to  a  full-sized 
organism  and  then  again  divides.  This  process  can  be  observed, 


1 1 


I 


, 

5678 
I  I  , 


FIG.  3. — Each  sido  of  the  square  represents  one-thousandth  of  an  inch.  The  relative 
size  is  then  shown  of  ( I)  a  red  blood-corpuscle,  (2)  the  anthrax  bacillus,  (3)  the  typhoid 
bacillus,  (4)  the  tubercle  bacillus,  (5)  the  influenza  bacillus,  (6)  the  diphtheria  bacillus, 
(7)  the  tetanus  bacillus,  (8)  a  micrococcus. 

and  has  been  shown  to  take  place  under  favorable  conditions  in 
about  twenty  minutes.  The  result  is  a  rapidity  of  multiplication 
that  is  difficult  to  comprehend.  A  simple  calculation  will  show 
that  if  this  rate  of  increase  continued  uninterrupted  for  a  period 
of  twelve  hours  we  should  then  have  arising  from  a  single  organism 
a  number  equal  to  more  than  ten  times  the  entire  human  popula- 


20  INFECTION 

tion  of  the  globe.  Under  natural  conditions,  of  course,  many 
influences  check  this  process,  but  multiplication  is  nevertheless 
enormously  rapid.  Some  species  of  bacilli  produce  spores,  a 
method  of  reproduction  somewhat  analogous  to  seed  formation 
in  higher  plants.  The  spore  appears  in  the  middle  or  end  of  the 
bacillus  as  a  bright  glistening  body,  the  bacterial  cell  later  melting 
away  and  leaving  the  spore  free  (Fig.  10).  Each  cell,  except  in 
rare  instances,  produces  only  a  single  spore,  so  that  multiplica- 
tion does  not  result  from  this  process.  The  office  of  the  spore 
appears  to  be  to  preserve  the  species  from  destruction  under 
unfavorable  conditions.  In  this  "resting  stage"  the  organism  is 
highly  resistant  to  heat  and  chemical  disinfectants  and  may  remain 
alive  for  years  in  the  dried  condition.  When  again  placed  under 


FIG.   4. — Diphtheria  bacilli.     (Microphoto-  FIG.    5.  —  Spirilli    of    Asiatic 

graph  by  Carr.)  cholera   (Carr). 

favorable  conditions  of  moisture,  temperature,  food  supply,  etc., 
the  spore  germinates  into  a  bacillus  and  the  process  of  reproduction 
by  fission  recommences.  Bacteria  absorb  nourishment  through  the 
external  surface  of  the  cell  from  the  surrounding  materials,  these 
being  acted  on  as  a  preparation  for  absorption  by  ferments  secreted 
by  the  cell.  Bacteria  thus  digest  their  food  outside  the  cell  body,  a 
process  which  results  in  chemical  changes  in  the  matter  surround- 
ing them;  changes  made  evident  in  the  various  processes  of  fer- 
mentation, putrefaction  and  decomposition  of  organic  substances 
resulting  from  the  action  of  "  saphrophytic  "  bacteria,  and  in  the 
case  of  the  disease-producing  or  "pathogenic"  species,  in  injury 
or  destruction  of  the  tissue  cells  of  higher  organisms  invaded  by 
them.  Abundant  moisture  is  essential  for  bacterial  growth.  The 


CELLS  OF  BODY  AND  INVADING  CELLS 


21 


JTIG   e  — Bacillus  subtilis  showing  flagellae  Fia.  7. — Diplococcus  pneumonia.   (Micro- 

(  Gray).  photograph  by  Carr.) 


-si, 


Fia.  8. — Streptococci.  (Microphotograph 
by  Gray.) 


Fia.  9. — Staphylococci.    (Micro- 
photograph  by  Carr.) 


Fia.  10. — Bacilli  showing  spores. 


22  INFECTION 

presence  of  air  or  free  oxygen  is  essential  for  the  growth  of  some 
and  absolutely  inhibits  the  growth  of  others.  The  former  are 
called  " aerobic,"  the  latter  "  anaerobic";  others  which  grow 
equally  well  in  both  conditions  are  known  as  "facultative" 
species.  As  they  are  seen  massed  in  "colonies"  on  the  surface 
of  culture  media  in  the  laboratory,  most  bacteria  are  grayish 
white  in  color,  but  many  species  produce  pigments  and  the  col- 
onies of  these  may  show  brilliant  coloring,  orange  yellow  or  red 
being  most  common,  but  blue-green  and  violet  coloring  may 
also  occur.  The  limits  of  temperature  within  which  bacteria 
grow  are  rather  wide.  For  each  species  there  is  an  upper  and  a 
lower  limit  above  or  below  which  growth  will  not  take  place; 
between  these  is  an  optimum  temperature  most  favorable  for 
growth;  above  the  maximum  temperature  for  growth  is  the  ther- 
mal death  point  at  which  the  organism  is  killed.  All  vegetative 
(not  spore-bearing)  forms  are  destroyed  by  a  temperature  con- 
siderably below  the  boiling  point  of  water.  Spores  withstand  a 
temperature  much  higher  than  this  for  a  considerable  time. 
Freezing  does  not  kill  bacteria  with  certainty,  and  some  may 
withstand  even  the  extreme  low  temperature  of  liquid  air.  Most 
vegetative  forms  are  readily  killed  by  drying,  but  some  may 
survive  for  days  or  even  weeks.  Bacteria  are  destroyed  by  chemi- 
cal agents  such  as  carbolic  acid,  iodine,  bichloride  of  mercury 
and  a  host  of  others,  but  in  every  known  instance  those 
chemical  substances  which  kill  bacteria  are  equally  or  even  more 
destructive  to  the  cells  of  the  human  body,  so  that  we  can- 
not combat  bacterial  infection  by  means  of  drugs  administered 
in  the  hope  of  destroying  the  invading  cells  without  poisoning 
the  patient.  The  readiness  with  which  bacteria  are  cultivated 
in  the  laboratory,  upon  simple  and  easily  prepared  media,  by 
the  methods  introduced  by  Koch,  has  resulted  in  a  great  accu- 
mulation of  knowledge  concerning  them  which  has  been  applied 
in  many  ways  in  the  prevention,  diagnosis  and  treatment 
of  disease. 

2.  The  Protozoa. — These  are  unicellular  organisms  which  are 
classed  as  belonging  to  the  animal  kingdom,  while  the  bacteria 
are  regarded  as  vegetable  in  nature.  The  species  of  protozoa 
are  very  numerous  and  they  are  very  widely  distributed,  being 
present  everywhere  in  sea-water,  in  all  stagnant  fresh  water, 
and  in  all  moist  soils.  Active  living  forms  are  never  present  in 
the  air,  but  many  are  able  to  pass  into  a  resting  stage  in  the  form 


CELLS  OF  BODY  AND  INVADING  CELLS  23 

of  spores  or  cysts,  in  which  condition  they  may  survive  for  some 
time  in  the  dried  state  and  be  carried  through  the  air.  They  are 
often  parasitic  in  habit,  and,  while  comparatively  few  species 
are  the  cause  of  disease  in  man,  many  others  cause  disease  in 
domestic  animals  and  plants  which  are  useful  to  man.  The 
protozoa  are  far  more  complex  and  varied  in  form  than  the  bac- 
teria, and  many  of  the  single  cells  show  remarkable  complex 
appendages  and  other  variations  of  structure  comparable  to  the 
specialized  organs  of  the  higher  forms  of  life.  Their  modes  of 
multiplication  are  also  more  complicated  and  varied  than  in  the 
case  of  the  bacteria.  Bacteria,  like  plants,  absorb  their  nourish- 
ment from  substances  in  solution  in  the  fluid  surrounding  them. 
The  protozoa,  like  animals,  derive  their  food  from  other  organ- 
isms, chiefly  bacteria.  They  do  not  multiply  so  rapidly  as  the 
bacteria.  Except  in  a  very  few  instances  it  has  not  been  found 
possible  to  cultivate  them  in  the  laboratory. 

3.  Yeasts  and  Moulds. — Infections  with  single-celled  organ- 
isms of  this  class  do  occur,  but  they  are  few  and  rare  and  need 
not  be  considered  here. 

4.  The  Filterable  Viruses. — There  is  still  another  class  of 
infections  our  knowledge  of  which   stands   in    a  very  curious 
position.    These  diseases  can  be  transmitted  to  a  healthy  animal 
by  injecting  into  its  tissues  a  very  small  quantity  of  the  blood 
or  of  certain  secretions  from  a  diseased  animal,  and  this  can  be 
done  even  after  the  blood  or  secretion  has  been  passed  through 
a  porcelain  filter,  the  pores  of  which  are  fine  enough  to  stop  the 
smallest  known  bacteria.    These  germs,  whatever  they  are,  must 
be   from  five  to  ten  times   smaller  than  the   smallest  of  the 
bacteria.     At  least  three  human  diseases  belong  to  this  class: 
yellow  fever,  the  disease  known  as  infantile  paralysis  or  polio- 
myelitis, which  especially  affects  children,  and  a  tropical  disease 
known  as  dengue  or  bmik-boiie  fever.     Altogether  some  twenty 
diseases  of  this  nature,  affecting  plants  and  animals,  are  known. 
No  filterable  organisms  not  related  to  disease  have  ever  been 
demonstrated. 

5.  Unknown  Invaders. — In  spite  of  all  the  study  that  has 
been  devoted  to  the  infectious  diseases,  there  are  still  a  number 
in  which  the  infectious  agent — the  invading  cell — has  not  been 
found.    Among  these  are  such  prevalent  diseases  as  measles  and 
scarlet  fever.    We  know  that  they  are  infectious;  we  know,  there- 
fore, that  they  must  be  due  to  a  living  agent,  an  invading  cell, 


24  INFECTION 

but  as  to  what  the  invaders  may  be  like,  we  are  up  to  the  present 
time  utterly  in  the  dark. 

Finally,  there  are  a  few  diseases  about  which  our  knowledge 
is  even  less.  They  may  possibly  be  infectious  in  origin,  but  we 
cannot  prove  either  that  this  is  true  or  that  it  is  not  true.  In 
argument  we  may  make  a  plausible  case  on  either  side,  but  there 
is  no  convincing  evidence  to  decide  the  question.  The  malignant 
tumors  perhaps  are  the  most  notable  diseases  in  regard  to  which 
we  are  in  this  unfortunate  position. 


CHAPTER  II 

SOURCES  AND  MODES  OF  INFECTION 
I.    NUMBER  OF  SPECIES  CONCERNED 

WE  have  defined  infection  as  a  disturbance  of  the  normal 
activities  of  the  cells  of  the  body,  due  to  an  invasion  of  its  tissues 
by  alien  cells  from  without.  We  have  seen  that  the  world  about 
us  is  teeming  with  invisible  life,  consisting  of  countless  species 
and  varieties  of  single-celled  organisms,  infinitely  small  and  insig- 
nificant individually,  but  irresistibly  potent  because  of  their 
prodigious  numbers,  and  the  almost  inconceivable  rapidity  with 
which  they  multiply.  In  the  great  majority  of  instances  the 
work  they  do  is  to  dissolve  and  melt  away  dead  organic  matter 
wherever  it  may  be  found;  a  beneficent  work,  for  the  most  part, 
in  its  relation  to  the  welfare  of  mankind,  since  without  it  there 
would  be  no  decay,  the  soil  would  soon  become  exhausted  of  its 
fertility,  and  the  surface  of  the  earth  choked  with  its  own  dead. 

A  certain  number  of  species,  however,  are  parasitic  in  their 
habits;  that  is,  their  natural  dwelling  place  is  within,  or  on,  the 
living  bodies  of  some  of  the  higher  many-celled  organisms.  Some 
of  these  parasites  do  no  harm  to  their  hosts,  but  others  cause 
serious  and  often  fatal  injury  to  the  tissue  cells  of  the  higher 
organisms  upon  which  they  live,  giving  rise  to  many  diseases  in 
plants,  in  the  lower  animals,  and  in  man.  Only  a  very  few 
species  among  the  myriads  are  able  to  become  hostile  invaders 
in  the  human  body,  scarcely  more  than  two  score  altogether, 
although,  if  we  include  all  the  occasional  invaders  and  some  which 
are  quite  incapable  of  doing  serious  harm,  this  number  will  be 
somewhat  increased.  On  the  other  hand,  if  we  include  only  those 
that  are  of  special  importance,  because  of  their  wide  distribution 
and  the  high  mortality  for  which  they  are  responsible,  we  shall 
have  a  list  that  can  almost  be  counted  on  the  fingers.  Our 
business  here  concerns  only  those  which  are  of  importance  in 
relation  to  wound  infection,  including  some  half-dozen  species 
of  bacteria;  but  before  we  can  begin  the  study  of  these  under- 
standingly  we  need  to  have  clearly  in  mind  certain  facts  about 
the  sources  and  modes  of  infection. 

25 


26  INFECTION 


II.  DISTRIBUTION  OF  BACTERIA 

1.  In  the  Air. — If  we  expose  to  the  air  for  ten  minutes  a 
thin  layer  of  culture  jelly  contained  in  one  of  the  small  glass 
plates  or  "Petri  dishes,"  and  then  replace  the  cover  and  put 
the  plate  in  the  incubator  over  night,  we  shall  find  next  morning 
upon  the  surface  of  the  medium  a  number  of  little  round  colonies 
of  bacteria  an  eighth  to  a  quarter  of  an  inch  in  diameter,  looking 
like  little  drops  of  paint.  Each  colony  will  have  grown  from  a 
single  germ  that  has  fallen  upon  the  surface  of  the  plate  while 
it  was  uncovered.  There  may  be  only  five  or  six,  or  there  may 
be  twenty  or  thirty  or  more  of  the  colonies,  representing  a  variety 
of  different  species.  There  will  certainly  be  some  of  a  yellow 
color,  some  gray,  and  possibly  some  of  a  bright  red.  There  will 
very  likely  be  some  of  the  fluffy  growth  that  we  recognize  as 
mould.  The  number  of  colonies  will  vary;  in  a  quiet  room  there 
will  be  few,  in  a  dusty  one  many.  Bacteria  are  sticky  things 
and  apt  to  adhere  to  particles  of  dust.  There  will  be  more  in 
the  city  streets  than  in  the  country;  more  in  the  lowlands  than 
in  the  mountains;  comparatively  few  or  none  at  sea,  in  desert 
regions,  and  particularly  in  polar  regions.  Among  them  micro- 
cocci  and  moulds  will  predominate.  It  will  be  rather  unusual  to 
find  any  of  the  pathogenic  species  upon  our  plate.  Most  of  them 
come  from  the  great  reservoirs  of  saprophytic  bacteria  that  are 
found  in  decomposing  vegetation. 

2.  In  Water. — In  water  we  should  find  bacteria,  for  the  most 
part,  far  more  numerous  than  in  the  air.  Here  we  must  use  a 
smaller  measure  for  our  standard.  It  is  usual  to  estimate  the 
number  in  a  cubic  centimetre,  a  quantity  about  equal  to  sixteen 
drops.  In  a  mountain  spring  trickling  from  the  rocks  and  in 
deep  wells  we  may  find  the  water  almost  sterile,  that  is,  containing 
few  bacteria  or  none.  They  have  been  filtered  out  in  their  pas- 
sage through  the  deeper  layers  of  the  soil.  In  an  ordinary  stream 
the  water  will  probably  be  found  to  contain  from  two  or  three 
hundred  to  five  thousand  or  more  bacteria  per  cubic  centimetre. 
In  a  polluted  stream  the  number  may  rise  to  enormous  totals,  a 
million  up  to  fifty  million  or  even  more  per  cubic  centimetre. 
Both  bacilli  and  micrococci  will  be  found  here  in  abundance. 
But,  except  in  specimens  taken  from  sewage-polluted  streams, 
disease-producing  germs  are  not  numerous. 

A  rapidly  flowing  stream  tends  quickly  to  purify  itself,  and 


SOURCES  AND  MODES  OF  INFECTION  27 

a  few  miles  below  a  point  of  contamination  the  number  of  bacteria 
contained  will  be  found  to  be  greatly  diminished. 

3.  The  Soil. — The  superficial  layers  of  the  soil  contain  bacteria 
in  great  abundance.      In  all  moist  soils  contaminated  by  animal 
excreta  or  decaying  vegetation  the  number  is  enormous.     In  a 
dry  soil  not  subject  to  such  contamination  the  number  is  relatively 
small.    At  about  three  feet  below  the  surface  the  earth  becomes 
practically  sterile,  no  bacteria  being  ordinarily  found  below  this 
level  except  in  loose  gravel,  where  they  may  be  present  at  a 
somewhat  greater  depth.     All  the  varieties  of  bacteria  are  in- 
cluded among  those  found  in  the  soil,  but  it  may  be  noted  that 
the  spore-bearing  bacilli  are  relatively  numerous  here.     Here, 
too,  is  the  chief  abode  of  moulds  and  other  fungi,  including 
yeasts,  and  very  many  species  of  single-celled  animals  are  also 
present.    Bacteria  which  are  pathogenic  to  man  are  present  in 
the  soil  in  populous  areas  contaminated  by  human  and  animal 
excreta.  Mountainous,  arid  and  unpopulated  areas  in  the  temper- 
ate zone  are  comparatively  free  from  pathogenic  germs.    Besides 
the  ordinary  pus  producing  micrococci,    the   tetanus   bacillus 
and  septic  gas  bacilli  are  most  to  be  feared.     Moisture  in  the  soil 
favors  their  growth  and  preservation.    These  facts  were  tragically 
illustrated  in  the  battle  wounds  in  France  and  Belgium,  where 
the    heavily    manured   soils   were   saturated   with    pathogenic 
bacteria.     All  wounds  suppurated.    Tetanus  was  common,  and 
gas-bacillus  invasion,  with  resulting  gangrene,  was  a  veritable 
scourge.     In  the  mountainous  sectors  of  Italy  wound  infection 
was  comparatively  light. 

4.  Food. — The  presence  of  bacteria  in  various  articles  of  food 
is  constantly  manifested  by  the  evidence  of  decomposition.    We 
may  take  milk  as  a  typical  example.     What  may  be  called  the 
normal  bacterial  content  of  milk  is  surprisingly  large.     Milk 
containing  no  more  than  ten  thousand  bacteria  to  the  cubic 
centimetre  is  considered  the  standard  of  attainable  purity.    The 
production  in  marketable  quantities  of  milk  in  which  the  bacteria 
do  not  exceed  this  number  is  rarely  attained.     A  milk  that  does 
not  contain  over  one  hundred  thousand  bacteria  to  the  cubic 
centimetre  is  regarded  as  just  passably  clean  by  most  of  our 
health  boards.     A  milk  containing  more  than  this  is  considered 
a  dirty  milk,  and  yet  in  all  probability  the  majority  of  the  milk 
now  marketed  contains,  at  the  time  it  reaches  the  table  of  the 


28  INFECTION 

consumer,  vastly  greater  numbers  of  bacteria  than  this,  often 
going  up  into  the  millions  per  cubic  centimetre.  It  is  true  that 
the  majority  of  these  bacteria  are  not  pathogenic,  often  not  even 
unwholesome;  nevertheless,  dangerous  and  deadly  disease  germs 
are  so  often  present  in  milk  that  the  methods  of  its  production 
and  distribution  are  among  the  most  important  of  the  problems 
concerned  with  the  prevention  of  infectious  disease.  Notable 
among  the  diseases  that  are  not  infrequently  conveyed  by  milk 
are  typhoid  fever,  streptococcus  infections  of  the  throat,  dysentery 
and  diarrhoeal  diseases  and  tuberculosis. 

Bacteria,  as  has  been  said,  readily  adhere  to  any  surface  they 
come  in  contact  with,  and  all  the  innumerable  articles  of  use  and 
ornament  that  surround  us  are  more  or  less  covered  with  them. 

5.  The  Human  Body. — The  skin  has  its  bacterial  flora,  dis- 
tributed not  only  on  the  surface  but  in  the  ducts  and  crypts  of 
its  glandular  organs.  Here  there  are  always  micrococci  capable 
of  giving  rise  to  the  infection  of  wounds,  and  many  other  infectious 
germs  may  at  times  be  found  upon  the  skin,  particularly  of  those 
who  come  in  contact  with  disease.  Bacteria  are  always  present 
and  even  multiply  abundantly  in  the  mouth  and  throat.  Here, 
also,  certain  species  capable  of  invading  the  body  may  be  prac- 
tically always  found  in  the  healthy  individual,  and  others  are 
occasionally  present.  Many  bacteria  swallowed  from  the  mouth 
and  taken  in  with  the  food  are  destroyed  in  the  stomach  by  the 
acid  gastric  juice,  and  that  portion  of  the  small  intestine  into 
which  the  food  passes  after  leaving  the  stomach  contains  fewer 
bacteria  than  any  other  part  of  the  intestinal  canal.  Lower 
down  in  the  intestine,  however,  the  bacteria  multiply  enormously 
until  they  actually  form  a  considerable  part  of  the  bulk  of  the 
contents  of  the  large  intestine.  From  one-eighth  to  one-quarter 
by  weight  of  the  dried  faeces  consist  of  bacterial  cells.  The  species 
present  in  the  intestines  are  fairly  constant  and  among  those 
normally  present  are  a  number  that  are  capable  of  invading  the 
body  tissues  under  certain  conditions. 

III.  THE  RELATION  OF  PARASITE  TO  HOST 

When  we  think  of  the  various  ways  in  which  infection  may 
come  to  us  it  is  natural  to  assume  that  the  germs  of  disease  always 
pass  directly  from  the  sick  to  the  well  and  that  the  means  of 
transmission  is  mainly  through  the  agency  of  the  air.  This  has 
probably  been  the  generally  accepted  idea  from  the  beginning 


SOURCES  AND  MODES  OF  INFECTION  29 

of  our  knowledge  of  these  diseases  and  still  influences  largely 
our  practice  in  regard  to  preventive  measures.  But  increasing 
knowledge  is  making  it  more  and  more  evident  that  the  problem 
of  the  sources  of  infection  is  far  from  being  so  simple  a  matter. 
An  individual  sick  with  an  infectious  disease  is  not  by  any  means 
the  only,  and  in  many  cases  not  the  chief,  source  of  infection  to 
others,  and  transmission  through  the  air  is,  with  a  few  excep- 
tions, an  almost  negligible  factor.  To  understand  this  we  must 
take  into  account  certain  facts  about  the  relation  of  parasite  to 
host.  We  have  said  that  the  presence  of  a  parasitic  organism  is 
not  necessarily  harmful  to  the  host,  and  we  have  also  pointed  out 
that  certain  individuals  of  a  species  may  be  apparently  entirely 
insusceptible  to  an  infectious  disease  to  which  other  individuals 
of  the  same  species  readily  succumb.  That  an  invading  organism 
will  grow  in  the  body  of  one  individual  and  not  in  that  of  another 
is  hard  enough  to  explain,  but  we  must  also  recognize  the  fact 
that  the  same  organism  may  grow  in  the  bodies  of  two  individuals, 
producing  symptoms  of  disease  of  the  gravest  character  in  one 
and  no  symptoms  whatever  in  the  other.  It  happens  often  that 
after  an  attack  of  disease  the  organisms  which  were  the  cause  of 
the  trouble  may  remain  alive  and  continue  to  multiply  in  the 
body  long  after  the  patient  has  fully  recovered;  but  it  is  also 
true  that  the  germs  of  an  infectious  disease  may  be  present  in 
the  body  of  an  individual  who  has  never  had  an  attack  of  the 
disease.  In  the  history  of  many  of  the  infections  there  are  found 
cases  where  the  symptoms  are  so  mild  that  they  are  scarcely 
recognizable,  and  it  is  but  a  step  farther  to  find  that  there  are 
cases  of  infection  with  no  symptoms  at  all.  How  greatly  these 
facts  complicate  the  problem  of  determining  and  controlling  the 
sources  of  infection  will  be  readily  seen,  but  even  this  is  not  the 
whole  story. 

When  an  organism  acquires  the  parasitic  habit,  there  is 
always  a  tendency  for  the  parasite  and  host  to  become  gradually 
adapted  or,  so  to  speak,  used  to  each  other,  so  that  the  mutual 
effects  of  a  harmful  nature  are  reduced  to  a  minimum.  It  is 
obvious  that,  when  the  presence  of  the  invader  is  rapidly  fatal 
to  the  host,  this  fact  works  as  much  to  its  own  disadvantage  as 
to  that  of  the  species  of  animal  invaded.  The  invaders  die  with 
their  victim,  and  their  chance  of  transmission  to  a  new  individual 
is  diminished  in  proportion  to  the  rapidity  with  which  they  kill. 
It  is  a  curious  fact  that  the  most  deadly  among  the  infections 


30  INFECTION 

are  also  the  most  rare;  thus  tetanus,  anthrax  and  rabies  are 
infections  that  almost  invariably  kill.  In  the  case  of  the  first 
two  of  these  named,  the  organisms  concerned  have  the  immense 
advantage  that  they  are  spore  producers  and  thus  are  able  to  sur- 
vive indefinitely  under  the  most  unfavorable  conditions.  Yet  the 
number  of  their  victims  is  small  in  proportion  to  their  deadliness. 

Heredity  plays  an  important  part  in  gradually  bringing  about 
a  mutual  adaptation  between  parasite  and  host.  The  individuals 
having  greater  resistance  to  the  invaders  are  the  ones  that 
survive,  to  transmit  this  quality  to  their  descendants;  on  the 
other  hand,  the  less  deadly  of  the  invading  organisms  are  favored 
in  their  chances  of  survival. 

Let  us  suppose  now  that  a  certain  unicellular  organism  has 
acquired  the  parasitic  habit,  living  in  the  body  of  a  certain  host, 
and  that  the  two  have  become  adapted  to  each  other  so  that  the 
host  suffers  little  or  no  injury  from  the  presence  of  the  parasite. 
The  host  in  this  case  we  will  suppose  is  one  of  the  wild  animals 
of  the  region,  or  perhaps  one  of  the  domestic  animals.  We  will 
call  this  the  habitual  host.  Suppose  now  that  the  same  organism 
is  also  able  to  invade  the  tissues  of  some  other  animal,  for  example 
the  human  body,  and  in  this  new  host  its  prp«^nce  gives  rise  to 
grave  disturbances.  We  shall  have  then  an  infectious  disease 
of  such  a  character  that  the  main  source  of  infection  is  not  from 
the  victims  of  the  disease  but  comes  rather  from  the  inexhaustible 
reservoir  found  in  the  bodies  of  habitual  hosts,  who  are  unaffected 
by  the  presence  of  the  organism.  This  is  exactly  the  condition 
of  affairs  with  regard  to  a  number  of  infectious  diseases  of  man 
and  of  the  domestic  animals,  and  it  is  quite  possible  that  there 
are  others  of  which  the  same  is  true,  although  the  habitual  host 
has  not  yet  been  discovered.  The  organism  which  is  the  cause 
of  sleeping  sickness,  a  disease  invariably  fatal  to  human  beings, 
which  prevails  in  certain  regions  of  Africa,  is  transmitted  by  a 
biting  fly  from  certain  wild  animals  of  the  region  who  are  its 
habitual  hosts.  The  domestic  goat  is  the  habitual  host  of  the 
micrococcus  which  is  the  cause  of  Malta  fever,  the  infection 
being  conveyed  through  the  milk.  There  is  evidence  that  septic 
streptococci  may  sometimes  be  present  in  the  milk  from  appar- 
ently healthy  cows,  and  it  seems  highly  probable,  though  per- 
haps not  proved,  that  milk  from  animals  which  show  no  outward 
sign  of  disease  is  one  of  the  sources  of  infection  with  the  tubercle 
bacillus. 


SOURCES  AND  MODES  OF  INFECTION  31 


IV.  CARRIERS  OF  DISEASE  ORGANISMS 

When  a  healthy  animal  or  human  being  is  the  bearer  of  an 
organism  which  is  capable  of  becoming  a  disease-producing 
invader  in  the  tissues  of  an  animal  of  another  species,  or  of  another 
individual  of  its  own  species,  we  speak  of  it  as  a  disease  "carrier." 
Diseased  individuals  are  of  course  also  carriers  of  disease,  but 
we  use  the  word  with  reference  particularly  to  healthy  carriers. 
Among  human  beings  we  have  chronic  carriers,  or  those  who, 
having  had  an  attack  of  disease,  retain  the  invading  cells  actively 
growing  in  their  bodies  for  an  indefinite  time  after  they  have 
been  restored  to  perfect  health.  We  have  also  healthy  carriers, 
or  those  who  have  never  had  an  attack  of  a  certain  infection 
and  yet  carry  in  their  bodies  the  organism  of  that  disease.  Wild 
or  domestic  animals,  and  also  insects,  which  are  the  habitual 
hosts  of  an  infectious  germ,  are  also  spoken  of  as  carriers.  A 
certain  number  of  those  who  have  recovered  front  typhoid 
fever  carry  in  the  intestinal  canal  living  and  active  typhoid 
bacilli  for  months  or  years,  or  even  for  the  remainder  of  their 
lives.  It  is  impossible  to  know  how  many  of  these  there  are, 
but  there  is  evidence  that  they  may  amount  to  two  or  three  per 
cent,  of  the  population.  Diphtheria  bacilli  are  often  present  in 
the  throat  for  weeks  or  months  after  recovery  from  the  disease, 
and  wherever  there  is  an  epidemic  they  are  also  to  be  found  in 
the  throats  of  a  varying  number  of  healthy  individuals,  some- 
times in  as  many  as  ten  or  fifteen  per  cent,  of  those  examined. 
With  regard  to  the  pneumococcus,  which  is  the  usual  cause  of 
pneumonia,  and  of  a  number  of  other  diseased  conditions  in  the 
human  body,  the  case  is  a  peculiar  one.  This  organism  is  harm- 
lessly present  in  the  mouths  of  a  large  percentage  of  human 
beings,  but  is  able  to  induce  an  attack  of  disease  only  under 
certain  conditions  which  favor  its  invasion,  probably  because  they 
lower  the  resisting  power  of  the  body.  Thus  prolonged  exposure 
to  cold  and  wet,  particularly  with  exhausting  labor,  favors  the 
development  of  pneumonia,  as  does  also  the  presence  of  certain 
other  infections,  the  administration  of  an  anaesthetic,  and  so  on. 

The  discovery  of  the  typhoid  carrier  was  felt  to  be  almost 
revolutionary  in  its  bearing  upon  our  conception  of  the  sources 
of  infectious  disease,  and  our  sanitary  authorities  have  been 
sorely  puzzled  as  to  the  proper  method  of  dealing  with  the  prob- 
lem. The  difficulties  of  detecting  these  carriers,  and  also  of 


32  INFECTION 

dealing  effectively  with  them  after  detection,  are  almost  insuper- 
able. Obviously  a  typhoid  carrier  whose  occupation  is  concerned 
in  any  way  with  the  preparation  of  food  is  a  constant  source  of 
danger  to  others.  Some  few  individual  instances  of  this  kind 
have  been  investigated,  showing  evidence  that  a  large  number 
of  persons  have  been  infected  by  a  single  carrier.  There  is  some- 
thing appalling  in  the  thought  of  such  an  unfortunate  individual 
going  through  life  unconsciously  leaving  behind  him  a  constantly 
lengthening  trail  of  disease  and  death.  And  yet  after  all  there 
was  nothing  really  new  or  revolutionary  in  this  discovery.  The 
facts  about  pneumonia,  which  we  have  stated,  had  long  been 
recognized,  and  for  many  years  it  had  been  known  that,  without 
exception,  every  surgeon,  nurse,  or  other  person  who  assists  in 
surgical  operative  work,  is  a  healthy  carrier  of  the  organisms 
concerned  in  wound  infection. 

V.  MODES  OF  TRANSMISSION 

The  dissemination  of  infectious  germs  from  the  sick,  the 
carriers,  or  the  animal  hosts  depends  on  the  method  by  which 
they  are  thrown  out  from  the  body.  In  some  diseases,  as  for 
example  in  malaria,  yellow  fever,  and  sleeping  sickness,  the 
organisms  cannot  find  exit  from  the  body  alive  unless  they  are 
withdrawn  directly  with  the  blood.  It  is  possible  to  transmit 
such  diseases  by  means  of  a  hypodermic  syringe,  but  the  ordinary 
method  is  by  the  bite  of  a  mosquito  or  other  insect.  The  principal 
avenues  by  which  infecting  cells  leave  the  body  are  through 
the  expectorated  secretions  from  the  mouth  and  throat,  the 
discharges  from  the  nasal  passages,  and  with  the  urine  and  faeces. 
Other  avenues  of  exit  are  the  secretion  of  milk,  discharges  from 
abscesses  and  ulcerations,  and  even  the  secretion  of  the  sweat 
glands.  As  a  rule,  probably  ninety  per  cent,  of  the  organisms 
so  eliminated  are  dead  at  the  time  they  leave  the  body,  but  the 
remaining  fraction  may  represent  prodigious  numbers.  The 
various  possible  modes  of  transmission  are  through  the  air, 
through  the  contamination  of  drinking  water  and  food,  through 
direct  contact,  and  through  contact  with  contaminated  articles, 
such  for  example  as  the  public  drinking  cup  and  all  the  innumer- 
able things  that  may  be  soiled  with  infection-bearing  secretions. 
Flies  and  other  insects  may  transmit  bacteria  mechanically  to 
articles  of  food  or  to  an  open  wound,  and  finally  the  importance 
as  bearers  of  infection  of  the  busy  human  fingers,  which  are  con- 


SOURCES  AND  MODES  OF  INFECTION  33 

stantly  touching  everything  within  their  reach,  can  hardly  be 
overestimated. 

There  are  two  ways  in  which  the  germs  of  disease  may  be 
disseminated  through  the  air.  One  is  through  the  drying  of 
infected  secretions  and  excretions  from  the  body,  which  are  then 
carried  about  by  air  currents  in  the  form  of  dust.  Most  of  the 
organisms  of  disease  do  not  live  very  long  when  dried,  particularly 
if  exposed  at  the  same  time  to  sunlight,  yet  some  of  them  can 
survive  under  these  conditions  for  several  days  at  least,  and 
certain  diseases  may  undoubtedly  be  transmitted  through 
inhaled  particles  of  infected  dust.  The  importance  of  this  method 
of  dissemination  has  quite  certainly  been  greatly  overestimated 
in  the  past,  and  it  is  probably  not  the  usual  mode  of  transmission 
in  the  case  of  any  infectious  disease  and  for  the  majority  is  a 
practically  negligible  factor.  The  other  mode  by  which  infectious 
organisms  are  carried  through  the  air  is  of  far  more  importance. 
It  is  the  so-called  droplet  or  mouth-spray  method.  In  talking, 
coughing,  or  sneezing,  and  even  in  breathing  through  the  open 
mouth,  there  is  always  driven  out  into  the  air  a  fine,  often  in- 
visible, spray  consisting  of  minute  droplets  of  mucus,  and  in 
these  droplets  there  are  invariably  present  some  of  the  bacteria 
of  whatever  kind  that  happen  to  be  present  in  the  mouth.  The 
spray  can  be  shown  experimentally  to  extend  for  a  considerable 
distance  up  to  several  yards,  though  ordinarily  five  or  six  feet 
is  the  limit  of  its  reach.  Any  infection  where  the  organism  is 
present  in  the  mouth,  nose,  or  throat  may  be  thus  conveyed, 
the  spray  being  directly  inhaled  or  more  often  perhaps  falling 
on  the  clothing  or  skin  surfaces,  particularly  the  hands,  of  persons 
standing  near,  to  be  later  conveyed  to  the  mouth.  Diphtheria 
and  influenza,  for  example,  are  doubtless  often  conveyed  in  this 
way.  Both  of  these  methods  of  conveyance  through  the  air  are 
of  course  more  liable  to  occur  in  a  closed  space,  like  a  room  or 
street-car,  than  in  the  open. 


CHAPTER  III 

INFECTION  IN  WOUNDS 
I.  DEFINITIONS 

WHEN  any  of  the  tissues  of  the  body  are  divided  or  separated 
by  violence,  as  for  example  by  a  cutting  or  tearing  or  crushing 
injury,  we  have  what  is  known  as  a  wound.  A  wound  may  vary 
in  extent  from  the  slightest  scratch  up  to  any  degree  of  severity. 
Accidental  wounds  are  described  under  various  terms  which 
indicate  their  character,  such  as  incised,  lacerated,  contused, 
and  punctured  wounds.  A  penetrating  wound  is  one  that  enters 
any  of  the  body  cavities,  such  as  the  head,  chest,  or  abdomen. 
A  snake  bite  is  an  example  of  what  is  meant  by  a  poisoned 
wound.  A  subcutaneous  wound  is  one  in  which  the  deeper  tissues 
have  been  torn  without  division  of  the  skin.  When  the  skin  is 
involved  we  speak  of  an  open  wound.  An  infected  wound  is  one 
into  which  living  single-celled  pathogenic  (disease-producing) 
organisms  have  found  entrance.  A  septic  wound  is  one  which 
is  infected  with  certain  species  of  bacteria  to  be  presently  de- 
scribed. A  suppurating  wound  is  one  from  which  pus  is  being 
discharged,  a  condition  always  the  result  of  septic  infection.  The 
word  sepsis  means  the  diseased  condition  of  the  body  due  to  the 
invasion  through  a  wound  or  otherwise  of  the  particular  species 
of  bacteria  concerned  in  septic  infection.  By  an  aseptic  ojr  clean 
wound  we  mean  one  which  is  entirely  free  from  all  microorganisms 
capable  of  giving  rise  to  local  or  general  injury  within  Ihe  body. 
The  healing  of  a  wound  is  the  process  of  repair,  due  to  the  activi- 
ties of  the  body-cells  of  the  wounded  part,  whereby  the  divided 
tissues  are  reunited  and  restored  more  or  less  perfectly  to  their 
natural  condition.  Normal  or  primary  healing  is  that  which 
takes  place  in  an  aseptic  wound. 

II.  OPERATIVE  WOUNDS 

The  wounds  which  particularly  claim  our  attention  are  those 

which  have  been  deliberately  made  by  the  surgeon,  with  some 

definite  purpose  of  a  remedial  character  in  view.    Such  wounds 

are  called  surgical  or  operative  wounds.     Any  remedial  measure 

34 


INFECTION  IN  WOUNDS  35 

carried  out  by  the  surgeon  with  his  hands  or  with  instruments 
is  called  an  operation.  A  bloodless  operation  is  one  in  which  no 
open  wound  is  made,  as  for  example  the  "setting"  of  a  fracture 
or  the  " reduction"  of  a  dislocated  joint.  Any  operation  which 
requires  the  making  of  an  incision  through  the  skin  or  mucous 
membrane  is  known  as  an  open  operation.  The  object  of  an 
open  operation  may  be  either  to  remove  something  contained 
within  the  body,  the  continued  presence  of  which  is  a  menace 
to  health  arid  life,  such  as  a  foreign  body,  a  diseased  or  injured 
organ  or  portion  of  tissue,  or  an  abnormal  accumulation  of  the 
products  of  disease;  or  else  to  correct  some  physical  or  mechanical 
defect.  The  special  characteristics  of  these  operative  wounds 
should  be  clearly  understood  by  the  nurse  in  order  that  her  work 
in  the  operating  room  air. I  in  the  care  of  surgical  cases  after 
operation  may  be  intelligently  performed. 

As  a  general  rule  every  open  surgical  operation  consists  of 
three  main  steps  or  stages:  (I)  exposure  of  the  part  to  be  operated 
on  is  secured  by  cutting  or  separating  the  overlying  tissues,  so  as 
to  bring  the  diseased  or  injured  area  clearly  into  view  and  make 
it  easily  accessible;  (2)  the  remedial  measures  required  ill  the 
particular  case  are  then  carried  out,  a  great  variety  of  procedures 
being  included  under  this  head;  (3)  closure  of  the  wound  is  accom- 
plished by  the  use  of  stitches  or  " sutures,"  so  as  to  restore  the 
parts  as  nearly  as  possible  to  their  normal  relations. 

The  first  step  begins  with  the  incision  through  the  skin  or 
mucous  membrane.  This  varies  in  position,  direction,  and 
extent  with  the  requirements  of  the  case.  It  may  be  a  single 
straight  or  curved  incision,  or  there  may  be  several  incisions 
joining  at  different  angles,  so  as  to  outline  (laps  of  skin,  which 
are  separated  from  the  underlying  tissue  and  temporarily  turned 
aside  out  of  the  way.  The  dissection  proceeds  with  the  division 
by  knife  or  scissors  of  the  superficial  fascia  or  t  issue  lying  immedi- 
ately under  the  skin,  with  its  layer  of  fat  of  varying  thickness, 
then  of  the  deep  fascia  covering  the  muscles,  and  finally  with  the 
separation  and  pulling  aside  of  the  muscles  and  other  structures 
overlying  the  part  to  be  operated  upon.  Large  nerves  are  never 
divided  in  this  procedure  and  large  arteries  or  veins  only  when 
absolutely  necessary.  Many  small  blood-vessels  are  necessarily 
cut,  and  bleeding  from  these  is  at  once  checked  by  pinching 
with  instruments  known  as  clamps  or  haemostatic  (blood-checking) 
forceps,  which  temporarily  compress  the  ends  of  the  divided 


36  INFECTION 

vessels.  Permanent  arrest  of  hemorrhage  is  later  secured  by 
tying  the  bleeding  points  with  threads  of  silk,  linen,  or  other 
material  specially  prepared  for  the  purpose.  These  ties  are  known 
as  ligatures  and  they  remain  permanently  in  the  wound.  Bleeding 
from  the  cut  capillaries,  too  fine  to  be  tied,  is  checked  by  pressure 
with  pads  of  gauze  called  sponges,  and  these  are  also  used  to 
soak  up  the  blood  which  at  times  obscures  the  field.  Many 
operations  require  the  opening  of  one  of  the  large  cavities  of 
the  body,  as  for  example  the  abdomen,  to  secure  access  to  the 
stomach,  the  intestines,  the  uterus  and  ovaries,  and  other  abdomi- 
nal organs.  The  other  large  cavities  to  which  a  way  of  entrance 
must  be  found  are  the  head  and  the  chest  or  thorax,  and  here, 
on  account  of  the  bony  walls  which  enclose  them,  special  means 
must  be  employed  involving  the  cutting  away  of  portions  of  ribs 
or  of  the  skull,  or  else  the  formation  of  flaps  containing  bone  as 
well  as  soft  parts,  which  can  be  temporarily  turned  aside,  exposing 
the  underlying  organs,  and  later  replaced  in  their  original  position. 
The  second  stage  consists  in  carrying  out  the  remedial  meas- 
ures to  accomplish  which  the  operation  was  undertaken,  and  may 
be  called  the  operation  proper.  It  includes,  of  course,  a  very 
great  variety  of  procedures  intended  for  the  relief  of  the  large 
number  of  injuries,  abnormalities,  and  diseases  that  are  amenable 
to  surgical  treatment.  They  are  too  numerous  and  varied  to 
be  briefly  summarized  here.  One  feature  of  operative  work 
remains  to  be  mentioned,  namely,  the  use  of  drainage.  All 
surgical  operations  fall  into  one  of  two  classes :  clean  cases,  where 
no  alien  invading  cells  are  present,  and  infected  cases.  The 
latter  include  those  where  the  operation  is  undertaken  for  the 
relief  of  conditions  resulting  from  septic  infection  in  some  part 
of  the  body.  In  these,  one  of  the  principal  objects  to  be  attained 
is  to  provide  for  the  escape  of  poisonous  accumulations  caused 
by  the  invading  organisms.  For  this  purpose  rubber  tubes  or 
wicks  of  gauze  are  inserted  through  the  wound,  extending  from 
the  skin  surface  down  to  the  infected  area,  so  as  to  keep  open  a 
way  for  the  escape  of  the  toxic  products  of  the  infection.  These 
drains,  as  they  are  called,  remain  in  place  for  a  variable  time, 
sometimes  for  weeks.  The  deadly  secretions  of  the  alien  cells 
are  by  this  means  continually  discharged  from  the  body  instead 
of  being  retained  and  absorbed,  thus  giving  the  body-cells  a 
great  advantage  in  their  struggle  with  the  invaders.  In  very 
deep  and  extensive  clean  wounds  temporary  drains  are  sometimes 


INFECTION  IN  WOUNDS  37 

inserted  to  prevent  the  retention  of  blood  and  serum  in  the  wound. 
They  are  removed  at  the  end  of  from  twenty-four  to  forty-eight 
hours. 

The  third  stage  in  a  surgical  operation  consists  in  closing  the 
wound  by  bringing  the  divided  tissues  together,  restoring  them 
to  their  normal  positions  and  relation  to  each  other,  and  fixing 
them  when  necessary  by  means  of  stitches,  or  " sutures,"  of  silk 
or  other  material.  The  cut  edges  of  the  incisions  in  the  skin  are 
united  with  particular  exactness  and  care.  Finally  the  wound 
is  covered  by  a  protective  "  dressing."  This  usually  consists  of 
loosely  woven  absorbent  gauze  laid  over  the  wound  and  held  in 
place  by  straps  of  adhesive  plaster,  bandages,  or  a  "  binder." 

Throughout  all  the  steps  of  an  open  operation,  from  the 
first  preparation  to  the  placing  of  the  dressing,  the  dominating 
idea  in  the  minds  of  every  one  engaged  in  the  work,  never  to  be 
forgotten  for  an  instant,  must  be  to  prevent  the  entrance  into 
the  wound  of  the  bacteria  of  septic  infection.  The  means  that 
are  used  to  attain  this  end  have  been  purposely  omitted  here, 
since  they  form  the  principal  theme  of  many  subsequent  chapters. 
In  this  place  we  are  concerned  rather  with  answering  the  questions 
as  to  what  happens  to  such  a  wound  when  no  infecting  organisms 
have  been  allowed  to  enter  it,  and,  on  the  other  hand,  what  is 
the  result  when  infection  has  occurred. 

III.  NORMAL  HEALING 

In  every  fresh  wound  there  will  occur  a  certain  amount  of 
oozing  from  the  divided  capillaries  and  lymphatic  vessels,  first 
of  bright  red  blood,  later  of  a  clear  fluid  only  slightly  blood 
stained.  In  very  extensive  operative  wounds  this  oozing  will 
be  of  considerable  amount  and  may  last  for  several  hours.  Later, 
at  the  first  dressing,  the  gauze  covering  the  wound  will  be  found 
deeply  stained  with  this  discharge.  Pain  in  the  wound  may  be 
present  immediately  after  the  operation,  but  it  is  rarely  severe 
and  ceases  within  a  few  hours.  Pain  is  more  often  due  to  too 
tight  bandaging  or  to  pressure  of  skin  stitches  than  to  the  wound 
itself.  Pain  resulting  from  movements  of  the  body  which  call 
into  play  the  muscles  in  the  region  of  the  wound  will  be  present 
for  several  days.  As  a  rule  there  is  no  elevation  of  the  temperature 
of  the  body  resulting  from  an  operative  wound  in  clean  cases 
(Fig.  11),  but  in  extensive  wounds  there  may  be  a  rise  of  from  one 
to  four  degrees,  beginning  within  twenty-four  hours  and  lasting 


38 


INFECTION 


FIG.  11. — Chart  showing  normal 
temperature  after  operation  (aalpin- 
gectomy). 


until  the  third  or  fourth  day  (Fig. 
12).  This  is  the  so-called  traumatic 
fever,  resulting  either  from  the 
absorption  of  the  dead  tissue  cells 
or  of  blood  that  has  collected  in 
the  wound,  or  else  from  increased 
oxidation  due  to  the  psychic  and 
traumatic  stimuli  of  the  operation. 
This  slight  fever,  occurring  within 
the  first  three  days,  is  quite  harm- 
less and  calls  for  no  interference 
with  the  wound.  On  the  other  hand, 
a  sudden  rise  of  temperature  appear- 
ing from  the  third  to  the  fifth  day 
almost  always  means  infection  (Fig. 
13),  and  if  it  persists  for  more  than 
twenty-four  hours  calls  for  a  change 
of  the  dressings  and  an  examination 
of  the  wound.  As  a  rule,  the  dress- 
ing of  a  clean  wound  is  allowed  to 
remain  undisturbed  for  from  five  to 
ten  days,  the  longer  the  better,  for 
there  is  always  some  risk  of  infecting 
a  wound  at  the  first  dressing  if  it 
is  done  too  early.  When  such  a 
clean  wound  is  dressed  and  the  skin 
stitches  removed  at  any  time  from 
the  fourth  day  onward,  the  edges  of 
the  skin  incision  will  be  found  to  bo 
quite  firmly  united,  there  will  be  no 
discharge  from  the  wound,  the  dress- 
ings being  free  from  moisture  al- 
though deeply  stained  with  dried 
blood.  The  skin  about  the  incision 
will  be  normal  in  appearance.  There 
will  be  no  redness  or  swelling  and 
scarcely  any  soreness  on  pressure. 
Even  very  extensive  wounds  will 
thus  appear  to  be  quite  perfectly 
healed  by  the  fourth  or  fifth  day 


Fia.  12  —Chart  showing  temperature  rise  due  to  trauma  and  not  to  infection. 
Amputation  for  crush  of  foot.     (Chart  by  Miss  Kathleen  Carroll.) 

39 


40 


INFECTION 


Fia.  13.— Chart  showing  septic  infection  after  operation.     (Excision  of  cystic  tumor  of 
breast,  local  abscess.)     (Chart  by  Miss  Virginia  Ryan.) 


INFECTION  IN  WOUNDS  41 

in  all  but  one  particular.  The  new-formed  tissue  resulting 
from  the  healing  process  is  still  soft  and  easily  torn.  What 
we  may  call  the  solidification  of  the  new  tissue  is  not  com- 
plete until  two  or  three  weeks  have  passed.  The  final  visible 
result  is  a  scar,  a  bond  of  new-formed  fibrous  or  connective  tissue 
solidly  uniting  the  wound  surfaces,  and  appearing  as  a  narrow 
line  along  the  site  of  the  incision.  At  first  the  scar  is  of  a  red  or 
purple  color,  owing  to  the  presence  of  numerous  capillary  blood- 
vessels, but  this  color  gradually  fades  away,  until  after  some 
weeks  the  scar  appears  much  whiter  than  the  surrounding  skin. 

IV.  INFECTED  WOUNDS 

There  are  many  varieties  of  single-celled  organisms  capable 
of  giving  rise  to  disease,  which  can  make  use  of  an  open  wound  as 
a  portal  of  entry  into  the  body,  but  when  we  speak  of  infection 
in  wounds  we  ordinarily  mean  septic  infection ;  that  is,  an  invasion 
by  certain  species  of  bacteria  which  cause,  when  growing  in  the 
tissues,  a  local  diseased  condition,  known  as  sepsis,  characterized 
by  inflammation,  delayed  healing  and  the  formation  of  pus, 
together  with  constitutional  disturbance  or  general  illness,  the 
most  prominent  symptoms  of  which  are  high  fever,  chills,  pro- 
fuse sweating,  and  digestive  disturbances. 

When  an  operative  wound  has  been  infected  with  the  bacteria 
of  sepsis,  the  course  of  events  will  be  somewhat  as  follows.  For 
the  first  two  or  three  days  there  will  be  no  disturbance,  the  condi- 
tion of  the  patient  being  the  same  as  in  normal  healing.  On  the 
third  or  perhaps  the  fourth  or  fifth  day  there  will  be  a  sudden 
rise  of  temperature,  of  probably  from  three  to  five  degrees, 
making  its  appearance  usually  in  the  afternoon.  There  will  be 
an  increase  in  the  pulse  rate.  There  may  be  a  sharp  chill  or  slight 
chilly  sensations,  known  as  rigors,  followed  by  more  or  less 
profuse  sweating.  Pain  in  the  wound  will  be  present,  and  may 
have  been  complained  of  before  the  fever  appeared.  On  the 
following  morning  the  temperature  will  be  found  to  be  nearly 
or  quite  normal,  but  in  the  afternoon  it  will  again  rise  to  a  higher 
level  than  before,  and  the  other  constitutional  symptoms  that 
have  been  referred  to,  together  with  digestive  disturbances  and 
restlessness,  will  be  increasingly  manifest.  This  type  of  fever 
with  a  sharp  rise  in  the  afternoon  and  a  drop  to  nearly  normal  in 
the  morning  is  quite  characteristic  of  septic  infection,  although 
in  many  cases  the  fever  is  more  continuous  in  character  and  often 


42  INFECTION 

irregular  (Fig.  14).  When  the  dressings  are  removed  and  the 
wound  is  exposed  to  view,  a  characteristic  appearance  will  present 
itself.  The  tissues  in  the  neighborhood  of  the  wound  may  be 
markedly  swollen,  rendering  the  skin  stitches  quite  tense.  The 
skin  about  the  incision  will  be  of  a  bright  red  color  unless  the 
infection  has  begun  in  the  deeper  part  of  the  wound  and  has  not 
yet  extended  to  the  surface,  in  which  case  there  may  be  little 
change  in  the  color  of  the  skin.  To  the  touch  the  tissues  about 
the  wound  will  be  distinctly  warmer  than  other  parts  of  the  body 
and  the  wound  itself  will  be  exquisitely  tender.  These  symptoms, 
swelling,  redness  of  the  skin,  heat  and  pain,  are  the  so-called  car- 
dinal signs  of  inflammation,  which  is  usually  defined  as  a  condi- 
tion entered  into  by  the  tissues  as  a  result  of  irritation,  in  this 
case  from  the  presence  of  septic  bacteria.  When  the  stitches  have 
been  cut  the  edges  of  the  wound  will  readily  separate,  allowing 
the  escape  of  a  more  or  less  abundant  discharge  of  a  pale  yellow 
fluid  material,  of  a  creamy  consistency  and  a  pasty  odor,  known 
as  pus.  When  a  wound  discharges  pus  it  is  said  to  bo  suppurating. 
The  color  and  consistency  of  pus  are  due  to  the  presence  of  enor- 
mous numbers  of  leucocytes,  which  have  found  their  way  into 
the  wounded  tissues  through  the  walls  of  the  blood-vessels.  They 
seem  to  be  attracted  to  the  locality  by  the  presence  of  the  invading 
organisms,  and  moreover  the  number  of  leucocytes  in  the  blood 
increases  in  cases  of  septic  infection  sometimes  to  as  much  as 
five  or  six  times  the  normal  number.  When  the  exudate  in  an 
infected  wound  has  the  character  of  pus  it  is  said  to  be  purulent. 
The  character  of*  the  exudate  varies  considerably  in  different 
cases.  If  very  few  leucocytes  are  present,  it  may  be  thin  and 
watery  and  it  is  then  described  as  a  serous  or,  if  blood  stained, 
as  a  serosanguineous  exudate.  If  coagulated  fibrin  is  present  in 
considerable  quantity  it  is  spoken  of  as  a  fibrinous  exudate. 

The  growth  of  septic  bacteria  within  the  body  often  results 
in  the  death  of  many  tissue  cells  and  a  breaking  down  and  lique- 
faction of  tissue  in  the  infected  area  so  that  a  cavity  is  formed 
which  becomes  more  of  less  rapidly  distended  with  an  exudate, 
usually  of  a  purulent  character ;  that  is,  one  containing  an  enor- 
mous number  of  leucocytes.  Such  a  cavity  containing  pus  is 
called  an  abscess. 

There  are  thus  to  be  found  both  local  and  general  symptoms 
and  signs  in  .septic  disease  due  to  wound  infection.  The  local 
disturbances  known  as  inflammation  and  suppuration  are  due 


INFECTION  IN   WOUNDS 


43 


2       g       8       $    \   §       §   I    3 


44  INFECTION 

to  the  direct  irritation  of  the  tissues  by  the  invading  bacteria 
and  their  toxic  secretions.  The  general  or  constitutional  symp- 
toms of  fever,  chills,  sweating,  digestive  disturbances,  and  so  on, 
are  caused  by  the  absorption  into  the  blood  stream  of  poisonous 
chemical  products  derived  from  the  infecting  organisms  and  from 
the  dead  tissue  cells  in  the  infected  area.  When  provision  is 
made  for  free  escape  of  the  exudate  containing  these  products 
the  poison  is  no  longer  absorbed  into  the  blood  and  the  symptoms 
due  to  its  presence  are  promptly  relieved.  When,  for  example, 
an  abscess  either  ruptures  spontaneously  or  is  laid  open  by  an 
incision  with  the  knife,  the  escape  of  the  pus  which  has  been 
confined  within  it  is  followed  by  almost  instant  fall  of  the  tem- 
perature to  normal  and  the  disappearance  of  other  symptoms 
which  accompany  the  fever.  The  treatment  of  septic  infection 
therefore  is  drainage,  and  when  this  can  be  satisfactorily  accom- 
plished the  chances  of  recovery  are  greatly  increased. 

V.  HEALING  IN  INFECTED  WOUNDS 

The  healing  of  an  infected  wound  appears  to  follow  a  very 
different  course  from  that  which  has  been  described  for  a  clean 
or  aseptic  wound,  although  in  reality  the  processes  involved  are 
essentially  the  same.  The  time  required  is  much  longer,  for  not 
only  does  the  presence  of  the  invading  cells  effectually  retard 
the  process,  but  the  necessity  for  drainage  of  the  wound  frequently 
requires  that  all  the  stitches  shall  be  removed  and  the  wound 
allowed  to  gape  widely  open,  so  that  a  very  much  larger  amount 
of  new  tissue  has  to  be  formed  to  fill  it  up.  This  new-formed 
tissue  is  known  as  granulation  tissue,  a  name  which  is  derived 
from  the  characteristic  surface  appearance  of  the  growth.  The 
color  of  this  granulation  tissue  is  a  bright  red,  and  the  surface 
is  not  smooth  but  granular,  showing  many  small  elevations  of 
uniform  size,  each  elevation  representing  a  capillary  loop.  The 
tissue  consists  of  young  connective-tissue  cells  and  newly  formed 
capillary  vessels,  the  same  in  character  as  those  which  form  to 
unite  the  edges  of  a  clean  wound  which  is  undergoing  normal 
healing  with  the  cut  surfaces  in  contact.  A  gaping  open  wound 
heals  by  filling  up  from  the  bottom  with  granulations  until  they 
are  level  with  the  surface,  after  which  the  new-formed  epithelial 
cells  growing  in  from  the  edges  gradually  cover  the  wound. 
Granulations  are  soft  and  easily  torn,  bleeding  readily  on  the 
slightest  touch,  but  the  unbroken  surface  offers  an  almost  im- 


INFECTION  IN  WOUNDS  45 

pervious  barrier  against  the  entrance  of  infecting  organisms,  and 
slight  injuries  are  rapidly  repaired,  so  that  a  granulating  wound 
is  comparatively  safe  from  infection. 

The  severity  of  septic  infection  in  a  wound  may  vary  in  every 
degree  from  a  superficial  and  insignificant  "  stitch  abscess  "  to  a 
rapidly  fatal  general  infection.  By  the  latter  term  we  mean  that 
the  bacteria  have  found  their  way  into  the  general  circulation 
and  are  growing  everywhere  in  the  body  instead  of  being  confined 
to  one  locality.  This  condition  is  known  as  septicaemia  when  it 
is  not  accompanied  by  the  formation  of  numerous  small  abscesses 
in  the  tissues,  often  at  a  distance  from  the  source  of  infection. 
Pyaemia  is  the  older  term  for  the  cases  of  general  infection  in 
which  multiple  abscesses  occur.  The  modern  term,  septco- 
pyaemia  is  to  be  preferred,  since  the  presence  of  multiple  abscesses 
is  an  indication  of  a  more  advanced  stage  of  septicaemia  rather 
than  of  a  different  disease. 

VI.  THE  SOURCES  AND  MODES  OF  SEPTIC  WOUND  INFECTION 

In  the  early  days  of  antiseptic  surgery  it  was  assumed  that 
the  air  was  the  source  from  which  the  germs  of  sepsis  came. 
Later  it  was  recognized  that  septic  infection  of  operative  wounds 
rarely  came  from  the  air,  but  almost  invariably  from  contact, 
the  bacteria  being  carried  in  by  anything  that  touched  the 
wounded  surface.  The  conception  then  was  that  all  material 
objects,  our  own  bodies  included,  of  course,  were  resting  places 
for  septic  bacteria,  which  gradually  accumulated  upon  them  from 
the  air,  although  the  air  itself  contained  comparatively  few  at 
any  one  time.  This  conception  revolutionized  our  operative 
technic,  bringing  in  the  era  of  so-called  aseptic  surgery.  It  was 
nearly  enough  true  to  enable  us  to  develop  our  technic  to  a 
high  degree  of  efficiency.  But  to  understand  the  real  situation 
it  is  necessary  to  go  one  step  farther.  It  is  a  fact  that  all  material 
objects  in  daily  use  about  us  are,  as  a  rule,  the  bearers  of  living 
bacteria  of  the  kind  that  cause  septic  disease,  but  why?  The 
reason  is  that  we  have  handled  them,  breathed  upon  them, 
sprinkled  them  with  mouth  spray,  silted  them  with  dust  rubbed 
from  the  surface  of  our  bodies  or  derived  from  its  dried  secretions. 
The  human  body,  healthy  or  not,  is  the  reservoir  from  which 
comes  the  ever-present  supply  of  septic  organisms.  Material 
objects  are  contaminated  in  proportion  as  we  handle  them.  In 
the  great  world  of  out  of  doors,  the  air,  the  water,  the  soil,  and 


46  INFECTION 

vegetation;  living  or  decaying,  are  comparatively  free  from  the 
germs  of  sepsis  when  they  are  not  contaminated  by  human  or 
animal  excreta.  Every  human  being  is  a  chronic  carrier  of  the 
organisms  of  septic  disease.  Wounds  are  infected  by  human  or 
animal  contact,  direct  or  indirect.  Accidental  wounds,  in  many 
cases,  are  infected  by  careless  handling  afterwards,  rather  than 
at  the  time  of  injury.  The  same  rigid  precautions  should  be 
exercised  in  dealing  with  them  as  in  the  case  of  operative  wounds. 

VII.  THE  BACTERIA  CONCERNED  IN  WOUND  INFECTION 

The  vast  majority  of  cases  of  septic  infection  in  wounds  are 
due  to  the  action  of  only  three  or  four  distinct  species  of  bacteria. 
There  are  a  number  of  other  occasional  invaders,  but  they  are 
so  rare  that  they  need  not  be  mentioned  here. 

1.  Staphylococcus  Pyogenes  (Fig.  15). — This  organism  is  the 
most  common  cause  of  septic  infection,  being  found  in  probably 
eighty  per  cent,  of  the  cases.     The  individual  cells  are  minute 
globular  bodies  (cocci),  and  they  appear  under  the  microscope 
in  irregular  masses,  suggesting  a  bunch  of  grapes  to  their  first 
observers,  who  named  them  in  accordance  with  this  character- 
istic.    "Pyogenes,"  meaning   pus-producing,  was  added  to  the 
name  to  distinguish  the  species  from  other  staphylococci  which 
do  not  cause  disease.    A  third  name  is  added  to  indicate  one  of 
several  varieties  or  allied  species,  and  this  is  usually  suggested 
by  the  color  of  the  growth  on  artificial  culture  media.     Aureus 
(golden  yellow)  and  albus  (white)  are  the  most  common  forms. 
These  bacteria  grow  abundantly  on  all  our  culture  media,  either 
in  the  presence  or  absence  of  air.     They  retain  their  vitality  in  the 
dried  condition  for  a  considerable  time,  and  are  rather  resistant 
to  chemical  disinfectants  and  to  heat.    Boiling  water  kills  them 
within  a  few  minutes.    Abundant  formation  of  pus  is  character- 
istic of  the  infections  with  which   they  are   concerned.     The 
Staphylococcus  pyogenes  aureus  is  the  variety  usually  found  in  the 
more  severe  infections,   and  the  albus  in  milder  cases.     This 
organism  is  very  often  present  on  the  skin,  in  the  mouth,  and  in 
the  intestines  of  healthy  individuals,  one  variety  of  the  Staphylo- 
coccus albus  being  a  quite  constant  inhabitant  of  the  human  skin. 

2.  Streptococcus  Pyogenes  (Fig.   16). — This    organism    holds 
the  second  place  in  point  of  frequency  among  the  bacteria  of 
sepsis.     From  another  standpoint  it  might   be  regarded   as  of 
first  importance,  since  on  account  of  its  extreme  virulence  in 
some  cases  it  is  more  to  be  dreaded  than  the  staphylococcus  as  a 


INFECTION  IN   WOUNDS  47 

cnuse  of  wound  infection.  The  most  rapidly  fatal  forms  of  infec- 
tion are  due  to  this  cause.  The  streptococcus  appears  under 
the  microscope  in  the  form  of  short  chains,  which  look  like 
strings  of  beads.  It  is  this  peculiarity  of  arrangement  that  enables 
us  to  distinguish  it  readily  from  the  staphylococcus,  since  the 
individual  cells  of  each  species  look  almost  exactly  alike,  appearing 
to  the  eye  under  the  microscope  as  very  small  spherical  bodies. 
It  is  easily  cultivated  on  our  culture  media,  growing  best  at 
about  the  body  temperature  and  in  the  presence  of  air.  It  is  a 
rather  more  delicate  organism  than  the  staphylococcus,  dying 
out  rapidly  under  conditions  that  are  unfavorable  to  it.  The 
character  of  the  inflammation  which  it  produces  in  the  tissues 
differs  from  that  caused  by  the  staphylococcus.  There  is  less 
tendency  to  the  formation  of  pus  and  tly  production  of  abscess 

v*  r 


,/"• 


Fie.    1."..        Sl.-iptiylocorons 
l>yo'_'(>nes  (Carr). 


cavities.  The  exudate  is  more  serous  or  watery  in  character, 
and  tends  to  infiltrate  the  tissues  and  to  extend  rapidly.  This 
organism  is  also  the  cause  of  erysipelas,  and  is  found  in  the 
majority  of  cases  of  puerperal  fever.  It  is  frequently  present  in 
the  mouth  and  intestinal  canal  in  both  man  and  lower  animals. 
(Ireat  variation  in  virulence  is  one  of  its  marked  characteristics. 
It  is  for  this  reason  perhaps  that  in  spite  of  its  wide  distribution 
infection  with  the  streptococcus  is  fortunately  less  common  than 
infection  with  the  staphylococcus.  When  it  does  occur  it  is 
regarded  as  the  most  serious  of  all  the  forms  of  septic  infection, 
and  in  some  cases  its  virulence  probably  surpasses  that  of  any 
other  organism  known.  In  every  case  of  erysipelas  or  other  form 
of  streptococcus  infection  occurring  in  a  hospital  the  most 
extreme  precautions  must  be  taken  lest  these  deadly  germs  be 
conveyed  to  healthy  wounds  either  at  an  operation  or  at  a  re- 
dressing. 


48  INFECTION 

3.  Bacillus  Coli  Communis  (Fig.  17). — A  number  of  closely 
allied  species  or  varieties  are  included  under  the  name  of  colon 
bacilli.  These  organisms  are  normal  inhabitants  of  the  large 
intestine,  and  form  the  largest  part  of  the  bacterial  content  of 
fecal  matter.  They  appear  as  short,  thick  rods  with  rounded 
ends.  Some  varieties  possess  motility  and  some  do  not.  None 
form  spores.  They  grow  readily  on  culture  media  either  with 
or  without  the  presence  of  air  or  oxygen.  They  withstand  drying 
well,  but  are  not  highly  resistant  to  heat  or  chemical  disinfec- 
tants. They  are  pus  producers  and  are  the  most  common  organ- 
ism found  in  cases  of  peritonitis  due  to  perforation  of  the  intestine 


Iwr 

wir& 

,.-V'< 


/" 


FIQ.    17. — Bacillus  coli  communis,  showing        FIG.    18. — Bacillus     pyocyaneus,     showing 
flagellae  (Gray).  flagellse   (Gray). 

with  escape  of  its  contents  into  the  abdominal  cavity,  although 
probably  always  associated  in  these  cases  with  pyogenic  cocci. 
In  operative  wounds,  the  colon  bacillus  is  sometimes  the  cause  of 
infections,  which  are,  however,  not  usually  of  a  very  severe  grade. 
4.  Bacillus  Pyocyaneus  (Fig.  18). — The  bacillus  of  green  pus 
is  an  occasional  invader  in  operative  wounds  and  is  usually  asso- 
ciated with  the  staphylococcus.  When  it  is  present,  the  pus 
discharged  from  the  wound  assumes  a  peculiar  bluish-green  color, 
for  which  the  organism  is  named.  It  is  a  small,  rod-shaped  organ- 
ism (bacillus),  provided  with  flagellse  at  each  end,  and  is  very 
actively  motile.  It  grows  readily  on  culture  media,  where  it 
produces  its  characteristic  pigment.  It  is  often  present  on  the 
skin  and  in  the  intestines  of  healthy  human  beings.  It  does  not 
form  spores. 


INFECTION   IN  WOUNDS  49 

VIII.  OTHER  INFECTIONS  OF  IMPORTANCE  IN  SURGERY 

The  bacteria  already  described  include  those  which  are  com- 
monly found  as  the  cause  of  septic  infection  in  operative  wounds. 
It  is  not  a  complete  list,  but  others,  being  of  less  frequency  and 
importance,  need  not  be  enumerated  here.  There  are  a  number 
of  other  organisms  which  are  able  to  use  a  wound  anywhere  in 
the  skin  or  mucous  membrane  as  an  avenue  of  entrance  to  the 
body,  and  which  give  rise  to  a  variety  of  diseases  which  are  not 
properly  classed  as  septic.  Two  of  these  must  be  enumerated 

.fi%£ffi$$%&' . 


Fia.  19. — Bacillus  tetani,  showing  flagellse          Fio.  20. — Bacillus  tetani,  showing  spores 
(Gray).  (Carr). 

on  account  of  the  deadly  character  of  the  diseases  caused  by  them, 
although  both  are  fortunately  rare  invaders  in  operative  wounds. 
1.  Bacillus  Tetani  (Figs.  19  and  20).— The  tetanus  bacillus, 
the  cause  of  the  disease  commonly  known  as  lockjaw,  is  a  small, 
slender  bacillus,  actively  motile  by  virtue  of  numerous  flagellae 
which  it  possesses.  Each  bacillus  produces  a  spore  at  the  end 
of  the  rod,  giving  it  a  characteristic  appearance  resembling  a 
drumstick.  It  is  a  strict  anaerobe,  growing  on  culture  media 
only  when  every  particle  of  oxygen  is  rigidly  excluded.  The 
spores  of  this  organism  are  exceedingly  resistant  to  heat  and 
chemical  disinfectants.  Boiling  for  an  hour  or  more  in  water 
is  barely  sufficient  to  kill  them,  and  they  survive  immersion  in 
powerful  disinfecting  solutions  for  many  hours.  They  are  found  in 
the  soil,  particularly  about  horse  stables,  being  a  frequent  inhabi- 
tant of  the  intestines  in  horses,  cattle,  and  sheep,  and  even  in  man. 
This  organism  produces  a  powerful  toxin  which  has  a  selective 
action  upon  certain  groups  of  cells  of  the  nerve  centres.  Tetanus 
4 


50 


INFECTION 


infection  results  in  death  in  the  great  majority  of  cases.  It  occurs 
most  frequently  in  accidental  wounds  contaminated  from  the  soil. 
2.  Bacillus  Aerogenes  Capsulatus(Fig.2l). — The  gas  bacillus, 
as  it  is  commonly  called,  is  a  large  bacillus  surrounded  by  a 
capsule.  It  is  not  motile,  and  is  strictly  anaerobic,  the  smallest 
amount  of  oxygen  or  air  preventing  its  growth  entirely.  It  forms 
spores  and  is  therefore  highly  resistant  to  drying,  and  heat.  In 
its  growth  it  produces  a  large  amount  of  gas,  and  in  the  tissues- of 
the  body  when  infected  by  it  this  is  manifested  by  great  disten- 
tion,  causing  a  tight  stretching  of  the  skin  over  the  part,  and  by 
a  crackling  sensation  felt  and  heard  when  the  finger  presses  on 
the  skin,  due  to  the  presence  of  gas  in  the  intercellular  spaces. 


FIG.  21.— The  gas  bacillus. 


FIG.  22. — Tubercle  bacilli  (Carr). 


It  is  a  widely  distributed  organism,  being  a  common  inhabitant 
of  the  digestive  tract,  and  is  frequently  found  in  water,  soil,  and 
dust,  but  fortunately  it  is  rarely  a  successful  invader  of  the  human 
body.  It  is,  on  /the  other  hand,  an  exceedingly  fatal  infecting 
agent  when  once  it  has  become  established. 

Finally,  brief  reference  must  be  made  to  three  forms  of  infec- 
tion which  call  for  special  attention,  not  so  much  as  possible 
invaders  in  operative  wounds  as  because  of  their  wide  prevalence 
and  great  surgical  importance. 

3.  The  tubercle  bacillus  (Fig.  22)  (Bacillus  tuberculosis)  is  a 
slender,  non-motile  organism  which  does  not  produce  spores.  It 
is  cultivated  with  difficulty  in  artificial  media,  growing  in  the 
presence  of  air  but  very  slowly  and  only  under  special  conditions. 
Special  staining  methods  are  also  required  to  make  it  visible  for 
microscopic  study.  Its  invasion  of  the  body  gives  rise  to  a  great 
variety  of  diseased  conditions,  involving  nearly  every  tissue  and 


INFECTION  IN  WOUNDS  51 

organ.  The  forms  of  tubercular  disease  which  are  amenable  to 
surgical  treatment  are  mainly  those  which  affect  the  bones, 
joints,  and  lymphatic  glands.  Many  cases  of  undoubted  infec- 
tion with  this  organism  through  operative  wounds  have  been 
noted,  but  this  mode  of  infection  is  so  easily  under  control  that 
it  can  only  occur  as  the  result  of  gross  ignorance  or  carelessness. 
The  usual  mode  of  infection  is  either  through  the  respiratory  or 
alimentary  tract.  With  the  exception  of  the  two  diseases  to  be 
mentioned  in  the  following  paragraphs,  tuberculosis  is  probably 
the  most  prevalent  disease  to  which  man  is  subject.  The  sources 


*!> 

i 


Fio.  23.— Trepomena  pallidum  (Gray). 

and  modes  of  its  invasion  are  not  yet  thoroughly  understood, 
and  the  question  of  its  control  is  one  of  the  great  problems  of 
preventive  medicine. 

4.  The  organism  which  is  the  cause  of  syphilis  (Treponema 
pallidum)  (Fig.  23)  is  a  slender,  corkscrew-shaped  rod,  actively 
motile  and  possessing  flagellae,  but  it  probably  belongs  to  the 
class  of  protozoa,  or  single-celled  animals,  rather  than  to  the 
bacteria.  It  finds  its  portal  of  entrance  into  the  body  almost 
always  through  slight  surface  wounds  of  the  skin  or  mucous 
membrane.  Like  the  tubercle  bacillus  it  is  not  a  serious  menace 
to  the  work  of  the  operative  surgeon,  and  for  the  same  reason. 
The  diseased  conditions  caused  by  syphilis,  like  those  of  tuber- 
culosis, are  of  great  variety  and  may  involve  any  tissue  or  organ. 


52  INFECTION 

The  most  prominent  manifestations  are  ulcerations  of  the  skin 
and  mucous  membranes,  and  the  destruction  of  tissue  cells  in 
extensive  local  areas  in  different  internal  organs.  Cases  of  this 
disease  are  always  to  be  found  in  the  wards  of  a  hospital,  often 
associated  with  other  surgical  conditions.  A  thorough  knowledge 
of  its  infectious  character  is  essential  for  the  nurse  on  account  of 
its  wide  prevalence  and  the  grave  character  of  the  disease  itself. 
The  organism  is,  in  the  vast  majority  of  cases,  conveyed  through 
direct  contact  with  an  infected  person,  though  infection  by  indi- 
rect contact  may  occur,  as  for  example  by  means  of  a  public 
drinking  cup,  or  any  contaminated  utensil  handled  by  an 
infected  person.  The  organism,  however,  does  not  long  survive 
outside  the  body  and  is  readily  killed  by  the  ordinary  means  of 

disinfection.  The  secretions  from  the 
ulcerative  lesions  are  particularly  infec- 
tious. 

5.  The  organism  of  Neisser  (gonococ- 
cus)  (Fig.  24)  is  a  diplococcus,  appearing 
under  the  microscope  as  two  incomplete 
spheres  with  flattened  surfaces  in  contact. 
It  is  a  pus-producing  organism  and  there- 
^ore  belongs  in  the  class  of  septic  bacteria, 
but  it  is  considered  here  apart  from  the 
others  in  order  to  emphasize  its  role  as  a  cause  of  disease  requir- 
ing surgical  treatment  rather  than  its  insignificant  importance 
as  an  infecting  agent  in  operative  wounds.  This  organism  has 
a  special  affinity  for  the  mucous  membranes,  particularly  of  the 
genito-urinary  tract  and  of  the  eye.  The  serous  membranes  are 
also  susceptible  to  it.  Many  cases  of  pelvic  disease  in  women  are 
caused  by  extension  of  this  form  of  inflammation  through  the 
uterus  and  Fallopian  tubes.  It  has  been  estimated  that  this  organ- 
ism is  responsible  for  eighty  per  cent,  of  deaths  from  inflammatory 
diseases  peculiar  to  women,  and  for  sixty  per  cent,  of  all  the  work 
done  by  gynaecologists.  The  serous  membranes  lining  the  joints 
may  be  infected  (gonorrhceal  rheumatism),  the  diplococci  being 
carried  to  them  by  the  blood  stream.  The  eyes  of  infants  born  of 
infected  mothers  are  frequently  involved,  resulting  in  blindness  in 
neglected  cases  (conjunctivitis  neonatorum) .  In  adults  also  destruc- 
tive inflammation  of  the  eyes  may  occur  from  this  form  of  infection. 
This  organism  is  very  delicate,  dying  out  in  a  few  hours  outside  the 
body  and  being  easily  killed  by  disinfectants  and  by  a  compara- 
tively low  degree  of  heat. 


PART  II— THE  FIELD  OF  SURGERY 


CHAPTER  IV 

SURGICAL  PATHOLOGY 
I.  DEFINITIONS 

1.  Affection. — Any  structural  change  or  abnormality  in  a 
tissue  or  organ  or  part  of  the  body  with  a  resulting  alteration  in 
the  functional  activity  of  the  part  involved  is  an  affection.    An 
affection  may  or  may  not  be  the  result  of  disease,  and  it  may  or 
may  not  be  the  cause  of  disease.    For  example,  an  alteration  in 
the  convexity  of  the  crystalline  lens  with  resulting  disturbance 
of  vision  is  an  affection  of  the  eyes  and  not  a  disease.    The  affec- 
tion in  this  case  is  not  produced  by  disease  and  does  not  give 
rise  to  any  diseased  condition,  except  perhaps  through  the  effect 
of  eye-strain  upon  the  nervous  system.    A  shrivelled  valve  in  the 
heart,  with  resulting  obstruction  to  the  onward  flow  of  the  blood, 
or  regurgitation  from  imperfect  closure  of  the  valve,  is  an  affec- 
tion of  the  heart  and  not  a  disease.     In  this  case,  however,  the 
affection  is  the  result  of  disease,  namely,  an  endocarditis  occurring, 
for  example,  in  the  course  of  an  attack  of  rheumatism.    It  also 
is  likely  to  become  sooner  or  later  a  cause  of  disease  in  distant 
organs,  particularly  the  kidney,  by  reason  of  the  disturbance  it 
produces  in  the  circulation  of  the  blood.    An  affection  which  is 
caused  by  a  disease  may  be  transient,  passing  away  with  recovery 
from  the  disease,  or  it  may  persist  for  a  certain  time  after  recovery, 
or  it  even  may  be  permanent. 

2.  Disease   is   an   active   process   depending  essentially  on 
altered  activities  of  some  of  the  cells  of  the  body  due  to  the  pres- 
ence of  abnormal  stimuli.    The  cells  are  thus  impelled,  not  to  do 
new  things,  but  to  do  too  much  or  too  little  of  the  things  they 
normally  do,  and  the  harmonious  interplay  of  their  activities  is 
interfered  with.    All  the  cell  faculties  may  be  affected,  nutrition, 
oxidation,  secretion,  and  reproduction.    The  death  of  some  cells, 
the   active   reproduction   of   others,    and   profound   nutritional 
changes   in   still   others  give  rise  to  visible  tissue  alterations, 
which  we  know  as  organic  changes,  and  these  in  turn  may  become 
the  basis  of  an  affection. 

When  disease  gives  rise  to  structural  change  in  any  tissue  of 

55 


56  THE  FIELD  OF  SURGERY 

the  body,  we  speak  of  it  as  an  organic  disease.  When  altered 
cell  activities  are  present  without  recognizable  tissue  changes,  we 
speak  of  the  disease  as  functional. 

An  acute  disease  is  one  of  sudden  onset  and  short  duration, 
measured  by  days  or  weeks.  A  chronic  disease  is  one  of  long 
duration,  measured  by  months  or  years.  A  chronic  disease  may 
have  an  acute  onset.  There  is,  of  course,  no  exact  time  limit,  and 
subacute  or  subchronic  are  used  as  intermediate  terms.  A  disease 
may  be  local  or  topical,  or  it  may  be  general  or  constitutional, 
according  as  the  disturbance  involves  a  part  only  or  the  whole 
body.  A  complication  is  a  disturbance  occurring  during  the 
course  of  a  disease,  arising  from  a  cause  wholly  or  in  part  different 
from  that  of  the  disease  itself.  Sequelae  are  the  late  and  remote 
effects  following  an  attack  of  disease.  Specific  disease  is  a  term 
which,  though  susceptible  of  a  wider  meaning,  is  commonly  used 
as  a  synonym  for  syphilis  or  lues. 

3.  Etiology  means  the  study  of  the  causes  of  disease.     An 
important  distinction  is  made  between  a  predisposing  cause,  or 
one  which  renders  an  individual  more  susceptible  to  an  attack 
of  disease  without  actually  producing  it,  and  an  immediate  or 
exciting  cause.     Exposure  to  cold  is  a  predisposing  cause  of 
pneumonia;  the  exciting  cause  is  the  invasion  of  the  pneumo- 
coccus.     The  exciting  causes  of  disease  are  those  agents  which 
give  rise  to  the  abnormal  stimuli  acting  on  the  body-cells.    They 
may  be  mechanical,  chemical,  physical,  or  living  agencies  inimical 
to  the  cell,  or  disease  may  be  caused  by  the  absence  or  the  pres- 
ence in  excess  of  substances  normally  used  by  the  cell.     The 
interaction  of  stimuli  between  the  groups  of  cells,  which  make  up 
the  glands  and  other  organs,  plays  a  role  of  great  importance  in 
the  complex  manifestations  of  disease. 

4.  A  lesion  is  any  organic  tissue  change.     Various  types  of 
lesions  are  given  special  names.    Hypertrophy  is  overgrowth  or 
increase  in  bulk  of  a  cell  or  tissue.     Atrophy  is  shrinking  or 
wasting.    Necrosis  is  the  death  of  the  cells  of  a  part  of  the  body. 
Degeneration  is  a  term  used  to  describe  many  forms  of  nutritional 
changes  in  the  cells  resulting  in  partial  or  complete  loss  of  their 
normal  activities.     Regeneration  is  the  rebuilding  or  renewal  of 
normal  tissue  cells.     Cicatrization  is  the  filling  of  a  defect  with 
fibrous  or  scar  tissue,  such  as  occurs  in  the  healing  of  wounds. 
Infiltration  is  the  distention  of  the  spaces  between  the  cells  with 
fluid  or  with  other  cells,  such  as  the  leucocytes.    Metaplasia  or 


SURGICAL  PATHOLOGY  57 

heteroplasia  are  different  forms  of  a  rare  condition,  namely,  the 
growth  of  normal  tissue  in  the  wrong  place,  as  the  growth  of 
bone  in  tendon,  cartilage,  or  muscle.  Neoplasia  is  the  formation 
of  new-growths  or  "  tumors  "  (neoplasms). 

Local  functional  disturbances  occur  without  alteration  of 
tissue  structure.  Hyperaemia  is  an  increased  flow  of  blood  to  a 
part.  Passive  congestion  is  a  damming  back  of  the  blood  in  a 
part.  Stasis  is  a  checking  of  the  blood  flow.  Local  anaemia  is  a 
diminution  of  the  normal  amount  of  blood  in  a  part.  Anaesthesia 
of  the  skin  is  a  loss  of  sensation  in  a  local  area.  Hyperaesthesia 
is  an  increased  sensitiveness  to  touch  and  pain. 

5.  Symptom. — A  symptom  is  any  recognizable  manifestation 
of  disease,  or  of  altered  function  resulting  from  an  affection. 
When  a  symptom  is  manifest  only  in  the  consciousness  of  the 
patient,  it  is  called  a  subjective  symptom;  when  it  is  manifest 
in  any  manner  to  the  observer  as  well  as  to  the  patient,  it  is  an 
objective   symptom.     Thus   nausea  is  a   subjective   symptom; 
vomiting  is  an  objective  symptom;  pain  is  a  subjective  symptom; 
the  observable  manifestations  of  pain,  the  cry,  the  facial  expres- 
sion, the  shrinking  from  pressure  on  the  painful  area,  are  objective 
symptoms. 

A  pathognomonic  symptom  is  one  which  is  known  to  indicate 
one  particular  disease  condition  and  one  only.  A  premonitory 
or  precursory  or  prodromal  symptom  is  one  which  tells  us  before- 
hand what  is  going  to  happen.  They  are,  in  other  words,  the 
earliest  manifestations  of  disease  which  appear  before  the  disease 
condition  has  developed  sufficiently  to  be  recognizable.  Local 
or  topical  symptoms  are  those  which  occur  in  a  particular  part 
or  organ  of  the  body.  General  or  constitutional  symptoms  are 
those  which  cannot  be  referred  to  one  locality,  such,  for  example, 
as  fever,  restlessness,  or  insomnia.  Symptoms  may  be  classified 
according  to  the  part  of  the  body  in  which  they  are  present,  as, 
for  example,  abdominal  symptoms,  gastric,  renal,  or  pulmonary 
symptoms.  Or,  they  may  be  classified  according  to  the  physio- 
logical system  involved,  as  respiratory,  circulatory,  digestive, 
sensory,  or  motor  symptoms.  A  localizing  or  focal  symptom  is 
one  which  indicates  the  exact  locality  of  a  lesion,  particularly 
in  the  brain  or  spinal  cord.  A  consistent  group  of  symptoms 
characteristic  of  a  particular  disease  condition  is  spoken  of  as  a 
symptom-complex  or  syndrome. 

6.  Physical    signs    are    the   recognizable   manifestations   of 


58  THE  FIELD  OF  SURGERY 

structural  or  organic  change,  that  is  of  an  affection.  They  are 
always  objective  in  character  and  in  many  cases  can  be  recog- 
nized only  by  a  skilled  and  practised  observer. 

Physical  signs  are  recognized  by  the  senses  of  sight,  touch,  and 
hearing.  By  inspection  we  note  the  general  condition  of  the 
patient  as  regards  nutrition,  the  presence  of  altered  contours  of 
the  body,  local  swellings,  changes  in  the  color  or  texture  of  the 
skin  and  mucous  membranes,  motor  disturbances,  the  facial 
expression,  and  so  on.  By  palpation  we  learn  through  the  sense 
of  touch  whether  any  part  is  harder  or  softer  than  normal,  the 
size,  shape  and  mobility  of  tumors,  the  presence  of  fluctuation 
indicating  fluid,  and  of  areas  that  are  painful  on  pressure.  By 
manipulation  we  detect  limitation  of  motion  in  joints,  abnormal 
points  of  motion  such  as  occur  in  fractures,  and  so  on.  In  men- 
suration we  use  the  tape  line  to  obtain  exact  measurements, 
usually  comparing  the  two  sides  of  the  body.  The  sense  of  hearing 
is  used  in  auscultation  to  determine  the  character  of  sounds 
within  the  body,  principally  in  examination  of  the  heart  and 
lungs.  In  percussion  the  ear  detects  differences  in  the  resonance 
or  sounds  produced  by  a  blow  with  the  fingers  upon  the  surface 
of  the  body.  This  is  used  almost  exclusively  in  examination  of 
the  chest  and  abdomen. 

7.  Signs. — The  word  sign  is  used  to  describe  certain  single 
symptoms  or  physical  signs,  usually  elicited  by  some  special 
manipulation  or  procedure,  and  supposed  to  be  pathognomonic 
of  some  particular  disease  or  affection.    Many  of  these  signs  have 
to   do  with   alterations   in  the   normal   muscle   reflexes    which 
have  been  observed  to  be  present  more  or  less  constantly  in  cases 
of  the  disease  in  question.     Very  many  such  special  signs  have 
been  described,  of  varying  value  and  importance,  and  they  are 
usually  known  by  the  name  of  the  discoverer.     For  example, 
Kernig's  sign  in  spinal  meningitis  consists  in  the  fact  that  the 
knee  cannot  be  fully  straightened  when  the  thigh  is  placed  at 
right  angles  to  the  trunk.     Graefe's  sign  in  exophthalmic  goitre 
is  the  failure  of  the  upper  lid  to  move  with  the  eyeball  in  glancing 
downward. 

Evidence  of  the  greatest  value  as  to  the  character  of  disease 
is  also  to  be  obtained  by  both  chemical  and  microscopical  exami- 
nations in  the  laboratory  of  the  blood  and  the  various  excretions, 
particularly  the  urine,  sputum,  and  fseces. 

8.  Diagnosis  and  Prognosis. — Diagnosis  is  the  act  of  deter- 


SURGICAL  PATHOLOGY  59 

mining  the  character  of  a  disease  and  of  the  lesions  and  affections 
produced  by  it.  Described  in  the  crudest  form,  it  is  the  act  of 
distinguishing  one  disease  from  another.  Prognosis  is  the  esti- 
mation of  the  probable  course,  duration,  and  outcome  of  a  disease. 
Diagnosis  in  many  cases  is  a  complex  and  difficult  problem,  for 
the  manifestations  of  disease  are  very  variable,  the  physical  signs 
often  obscure,  and  many  symptoms  or  even  groups  of  symptoms 
may  arise  from  widely  different  causes.  Clinical  diagnosis  is 
that  based  on  the  symptoms  of  the  disease,  physical  diagnosis 
is  based  on  the  physical  signs.  Pathological  diagnosis  is  that 
based  on  an  examination  of  the  tissues  and  organs  after  death. 
Differential  diagnosis  is  made  by  contrasting  the  symptoms  and 
physical  signs  of  two  diseases  that  are  liable  to  be  mistaken  for 
each  other.  A  presumptive  diagnosis  is  one  based  on  a  few 
prominent  symptoms.  A  provisional  diagnosis  is  one  made  with 
a  mental  reservation,  to  be  changed  if  further  evidence  presents 
itself. 

9.  Treatment  is  the  application  of  any  measure  designed  to 
assist  in  bringing  about  the  cure  of  disease,  or  relief  of  its  symp- 
toms, or  to  correct  a  disturbance  of  function  arising  from  an 
affection.     Therapeutics  or  therapy  is  the  general  term  for  all 
forms  of  the  treatment  of  disease.     Empirical  treatment  is  any 
form  which  we  have  learned  by  experience  to  be  efficacious  with- 
out knowing  the  reason  why.     Rational  treatment  is  that  based 
upon  reasoning  from  the  known  facts  about  the  disease  or  its 
causation.    Treatment  is  spoken  of  as  radical  when  it  is  directed 
to  the  removal  of  the  cause  of  the  disease,  symptomatic  when 
its  object  is  the  relief  of  the  symptoms  only  without  any  attempt 
to  remove  the  cause,  palliative  when  it  is  not  expected  to  cure 
the  disease  but  only  to  hold  it  in  check,  supporting  when  it  is 
mainly  directed  to  sustaining  the  strength  of  the  patient.    Specific 
treatment  is  the  use  of  a  single  remedy  which  has  a  definite 
curative  action  upon  a  certain  disease;  for  example,  quinine  in 
malaria,  mercury  and  salvarsan  in  syphilis,  diphtheria  antitoxin 
in  diphtheria.    In  the  treatment  of  disease  it  is  quite  as  important 
to  know  when  to  let  nature  alone  as  when  to  try  to  aid  her,  and 
this  attitude  is  expressed  by  the  term  "  expectant  treatment." 
Active  treatment,  on  the  other  hand,  consists  in  the  vigorous  use 
of  strong  remedies. 

10.  Pathology  is  the  science  which  treats  of  the  changes  that 
take  place  in  the  body  as  the  result  of  disease.    It  deals  both  with 


60  THE  FIELD  OF  SURGERY 

alterations  of  appearance  and  structure  in  the  tissues  and  organs, 
and  with  disturbances  of  function  in  various  parts  of  the  body 
mechanism.  The  causes  of  disease  also  come  within  its  scope  in 
finding  an  explanation  of  the  manner  in  which  different  harmful 
influences  act  upon  the  body.  Gross  pathology,  or  pathological 
anatomy,  treats  of  changes  in  the  tissues  that  are  visible  to  the 
naked  eye.  Pathological  histology,  or  cellular  pathology,  is  con- 
cerned with  changes  in  the  individual  cells  as  seen  under  the  micro- 
scope. Changes  in  the  body  functions  resulting  from  disease 
constitute  a  very  important  part  of  pathological  study  and  this 
department  is  described  by  the  rather  awkward  term  ''pathological 
physiology."  Surgical  pathology  is  the  pathology  of  surgical  con- 
ditions; i.e.,  of  those  diseases  and  affections  which  are  amenable 
to  surgical  treatment.  This  latter  is  obviously  a  very  artificial 
subdivision.  Pathological  processes  are  not  capable  of  separate 
classification  according  to  the  methods  of  treatment  that  happen 
to  be  applicable  to  them,  but  the  term  is  convenient  as  designating 
a  limited  part  of  the  field  when  discussed  in  surgical  treatises. 

II.  THE  MEANING  OF  PATHOLOGICAL  CHANGE 

Every  pathological  change  is  the  result  of  changes  in  the  activ- 
ities of  some  of  the  cells  of  the  body,  brought  about  by  various 
forces  which  act  as  stimuli  upon  the  cells.  The  normal  body  is 
of  course  the  seat  of  incessant  change,  and  very  many  pathological 
processes  can  be  paralleled  by  changes  which  occur  normally  in 
the  body.  It  is  impossible  to  frame  a  concise  definition  of  so 
complicated  a  subject  that  is  not  open  to  criticism,  but  a  helpful 
point  of  view  in  understanding  the  meaning  of  pathological 
changes  may  be  obtained  if  we  say  that  the  difference  between 
health  and  disease  consists  largely  at  least  in  the  fact  that  in  the 
normal  condition  a  certain  balance  is  maintained  in  the  activities 
of  the  cells,  whereas  in  diseased  conditions  this  balance  is  de- 
stroyed. Such  a  disturbance  of  balance  manifests  itself  in  a 
variety  of  ways.  For  example,  the  needs  of  the  organism  as  a 
whole  continually  require  that  one  or  another  group  of  cells  shall  be 
called  upon  temporarily  for  extra  work.  The  organism  is  so  consti- 
tuted that  in  such  a  case  influences  automatically  arise  which  urge 
these  cells  on  to  work.  When  the  extra  work  is  done  or  is  no  longer 
needed  other  influences  come  into  play  which  restrain  the  cells. 
Thus  the  organism  (e.g.,  the  human  body)  is  able  to  carry  on  its 
functions  normally  in  spite  of  changing  environment,  by  what  may 


SURGICAL  PATHOLOGY  61 

be  called  a  properly  balanced  adjustment  of  its  cell  activities.  If 
either  the  urging  influences  (exciting  stimuli),  or  the  restraining 
influences  (inhibiting  stimuli),  are  increased  or  suppressed  from 
any  cause,  then  the  cells  either  fail  to  do  the  work  needed,  or 
they  continue  in  riotous  and  undisciplined  activity.  Examples 
of  such  disturbance  in  the  equilibrium  of  cell  activities  are  in- 
numerable in  disease.  In  fevers  the  rise  of  temperature  and  the 
rapid  heart  action  are  manifestations  of  abnormal  increase  in 
cell  activity,  and  the  depressed  secreting  activity  of  other  cells 
is  seen  in  the  dryness  of  the  skin  and  mucous  membranes.  But 
a  disturbed  balance  may  be  shown  to  be  the  cause  not  only  of 
functional  changes  but  of  visible  physical  changes  as  well.  Thus 
in  the  healthy  body  fluid  is  constantly  leaking  through  the  walls 
of  the  capillary  blood-vessels  into  the  spaces  between  the  cells 
in  the  tissues.  This  fluid  bathes  the  individual  cells,  furnishes 
them  with  nutriment,  and  carries  off  their  waste  products. 
Normally  the  fluid  is  carried  off  exactly  as  fast  as  it  comes  in, 
passing  along  the  lymphatic  channels,  from  which  it  eventually 
returns  to  the  blood  stream,  while  a  part  is  thrown  off  in  the 
form  of  excretions  from  the  skin,  kidneys,  etc.;  if,  however,  less 
is  carried  off  than  comes  in,  this  fluid  accumulates  in  the  tissue 
interspaces;  they  become  soggy  with  watery  fluid,  and  we  have 
a  pathological  condition  known  as  O3dema.  Physical  changes  in 
individual  cells  are  also  due  in  many  cases  at  least  to  a  similar 
disturbance  in  balance.  Thus  every  cell  in  performing  work 
gives  out  energy,  and  in  doing  this  it  must  use  up  some  of  its 
own  substance  in  chemical  change.  This  used  substance  must 
be  replaced  by  an  equal  amount  of  substance  taken  into  the  cell 
from  the  material  surrounding  it.  The  work  of  the  cell  may  be 
done  quietly  and  almost  continuously,  or  it  may  be  done  with  a 
sudden  explosive  exercise  of  energy,  as  in  a  violent  muscular 
exertion.  In  the  latter  case  a  period  of  rest  must  follow  for  the 
cell  to  restore  the  substance  that  has  been  used  up.  In  either 
case  an  exact  balance  must,  in  the  long  run,  be  maintained 
between  what  is  used  up  and  what  is  taken  in,  if  the  cell  is  to 
maintain  its  normal  life.  If  more  is  used  up  than  is  taken  in 
the  cell  will  waste  away.  If  more  is  taken  in  than  is  used  the 
cell  will  increase  in  size.  In  many  chronic  diseases  particu- 
larly, alterations  in  the  nutrition  of  cells  give  rise  to  a  variety  of 
transformations  in  cell  substance  which  are  known  as  degenera- 
tive changes.  We  know  so  little  about  the  complex  chemistry 


62  THE  FIELD  OF  SURGERY 

of  these  processes  that  no  general  statement  can  properly  be 
made  in  regard  to  them,  but  if  these  degenerative  changes  are 
due,  as  is  possible,  to  an  excess  or  insufficiency  in  some  one 
link  in  a  chain  of  chemical  reactions  normal  to  the  cell,  then  we 
should  have  here  also  an  example  of  altered  balance  as  a  cause 
of  pathological  change. 

III.  THE  CAUSES  OF  DISEASE 

All  the  causes  of  disease  may  be  classified  as  either  mechanical, 
physical  or  chemical  in  nature;  i.e.,  every  change  in  cell  environ- 
ment must  in  the  last  analysis  fall  under  one  of  these  divisions. 
It  is  far  from  being  true,  however,  that  we  are  able  to  place  all 
the  facts  known  about  disease  causation  in  so  simple  a  classifica- 
tion. Consider,  for  example,  such  problems  as  inherited  abnor- 
malities, irregularities  in  nutrition,  overwork  and  disuse,  pre- 
disposition and  susceptibility,  the  influence  of  sex,  life  period, 
occupation,  etc. :  these  and  many  other  factors  in  causation  are 
so  exceedingly  complex  in  character  that  any  simple  systematic 
classification  of  them  is  quite  impossible.  We  can  consider  here 
only  some  of  the  more  obvious  causes  which  give  rise  to  conditions 
of  disease. 

1.  Mechanical  Causes. — Trauma,  or  direct  mechanical  injury, 
is  of  course  one  of  the  most  common  causes  of  abnormal  condi- 
tions of  the  body  calling  for  surgical  treatment.  Wounds,  frac- 
tures, dislocations,  sprains,  bruises,  and  a  variety  of  internal 
injuries  are  produced  by  direct  external  violence.  In  all  of  these 
there  is  destruction  of  tissue  cells,  rending  of  anatomical  struc- 
tures, always  including  blood-vessels,  with  an  escape  of  blood 
externally  or  into  the  tissue  spaces.  The  reaction  of  the  tissue 
cells  to  such  a  local  injury  constitutes  one  of  the  most  important 
parts  of  surgical  pathology,  and  will  be  considered  in  a  later 
paragraph.  Mechanical  pressure  is  a  potent  cause  of  harm,  having 
many  manifestations.  The  first  effect  of  pressure  upon  a  tissue 
is  to  squeeze  out  the  fluid  contained  in  it;  the  cells,  being  depend- 
ent upon  the  continuous  flow  of  this  fluid  about  them  for  their 
nourishment,  die  if  it  is  withheld  even  for  a  few  hours,  and  the 
result  is  therefore  death  of  tissue  in  the  compressed  area:  a 
condition  called  in  this  case  sloughing  or  gangrene.  Thus,  if  in 
putting  up  a  fracture  a  splint  is  allowed  to  press  too  tightly  upon 
the  skin,  particularly  over  a  point  where  a  bone  lies  near  the 
surface,  the  result  will  be  a  sloughing  of  the  skin  and  underlying 


SURGICAL  PATHOLOGY  63 

tissue.  Long-continued  pressure  not  severe  enough  to  shut  off 
the  circulation  entirely  has  a  different  effect.  The  cells  of  the 
part  undergo  what  is  known  as  atrophy;  i.e.,  they  waste  away. 
Even  a  solid  tissue  like  bone  will  thus  melt  away  by  pressure 
atrophy  from  the  presence  of  a  growing  tumor  or  an  aneurism. 
On  the  other  hand,  pressure  applied  to  a  part  not  continuously 
but  at  intervals  may  stimulate  cell  growth  and  cause  a  thicken- 
ing on  the  part,  as  in  corns  and  bunions  on  the  calloused  hands  of 
the  workingman.  Many  surgical  conditions  can  be  attributed 
to  mechanical  disarrangements  within  the  body  which  are  not 
due  to  external  violence.  For  example,  a  strangulated  hernia 
is  due  to  a  purely  mechanical  cause.  A  loop  of  intestine  is 
pinched  in  the  narrow  neck  of  the  hernial  sac  so  that  its  circu- 
lation is  cut  off,  with  a  resulting  gangrene  unless  relieved  by 
operation.  All  the  forms  of  intestinal  obstruction,  whether  by 
adhesion  bands,  kinks,  volvulus  (twisting),  intussusception  (tele- 
scoping), impaction  or  the  growth  of  a  tumor,  come  under  this 
head;  so  also  do  cases  of  obstruction  in  other  tubular  organs, 
such  for  example  as  the  plugging  of  the  outlet  ducts  of  glands 
giving  rise  to  retention  cysts,  or  the  shutting  off  of  the  flow  of 
urine  from  the  kidney  to  the  bladder  due  to  a  stone  lodged  in 
the  ureter.  Displacements  of  abdominal  organs  due  to  relaxation 
of  their  supporting  tissues  (sphinchnoptosis)  give  rise  to  a  peculiar 
group  of  symptoms  (Glenard's  disease),  including  dyspepsia, 
constipation  and  neurasthenia. 

2.  Physical  Causes. — These  include  the  effects  of  tempera- 
ture (heat  and  cold),  light,  electricity,  X-rays,  radium  rays.  The 
human  organism  is  almost  perfectly  adapted  to  light  of  any  inten- 
sity to  which  it  can  be  subjected,  and  to  a  very  wide  range  of 
temperature.  The  other  forces  mentioned  rarely  act  as  causes 
of  disease.  We  need  consider  here  only  the  effects  of  extreme 
degrees  of  heat  and  cold.  Burns  are  classified  as  to  severity  in 
four  degrees.  In  the  first  degree  there  is  simple  redness  of  the 
skin ;  in  the  second  degroe  there  is  a  separation  of  the  superficial 
layers  of  the  skin  by  effusion  of  serous  exudate  from  the  blood 
with  the  formation  of  blisters.  In  the  third  degree  the  deeper 
layers  of  the  skin  are  destroyed,  and  in  the  fourth  degree  the  whole 
thickness  of  the  skin  and  part  of  the  underlying  tissue  are  charred. 
A  second-degree  burn  of  half  the  surface  of  the  body  or  a  third- 
degree  burn  of  a  much  smaller  area  is  always  fatal.  Healing  of 
extensive  burns  of  the  third  degree  often  gives  rise  to  serious 


64  THE  FIELD  OF  SURGERY 

deformities  due  to  the  contraction  of  the  scar.  The  thermal 
death  point  of  tissue  cells  is  less  than  130°  F.,  so  that  water  bottles 
which  do  not  feel  very  hot  to  the  hand  may  cause  deep  burns  if 
left  in  contact  with  the  skin  of  an  unconscious  patient  for  even 
a  short  time. 

Tissue  cells  are  much  less  susceptible  to  destruction  by  cold 
than  by  heat.  Local  tissues,  as  of  the  hands  or  feet  for  example, 
may  even  recover  after  being  frozen,  provided  that  the  thawing 
process  is  very  gradual  and  that  the  brittle  frozen  tissues  are 
not  injured  by  manipulation.  Frost  gangrene  occurs  as  a  result 
of  mechanical  injury  to  the  frozen  tissue,  and  of  too  rapid  thaw- 
ing leading  to  paralytic  stasis  of  the  circulation.  On  the  other 
hand,  the  changes  of  temperature  which  the  organism  as  a  whole 
can  survive  are  comparatively  narrow.  The  reason  is  that  any 
marked  variation  from  the  normal  (or  optimum)  temperature 
inhibits  cell  activity,  and  if  the  action  of  certain  cells,  such  as 
those  which  control  respiration  and  the  heart  action,  becomes 
suppressed  death  ensues.  Thus  a  fall  of  the  body  temperature 
of  even  four  or  five  degrees  below  the  normal  is  apt  to  be  asso- 
ciated with  alarming  symptoms  of  collapse,  and  a  fall  to  ordinary 
room  temperature  (70°  F.)  is  always  fatal.  In  fever  a  rise  of 
temperature  to  106°  F.  is  of  grave  omen:  a  rise  to  109°  F.  is 
practically  always  fatal,  though  a  few  anomalous  cases  of  higher 
temperature  have  been  recorded. 

3.  Chemical  Causes. — Since  the  activities  of  living  cells  are 
so  largely  chemical,  it  is  obvious  that  they  are  likely  to  be  pro- 
foundly affected  by  any  marked  change  in  the  character  of  the 
chemical  substances  which  surround  them.  The  word  "poison" 
presents  a  familiar  idea  of  the  harmful  effect  of  a  chemical  sub- 
stance upon  a  living  organism.  A  change  in  the  chemical  en- 
vironment of  a  cell,  like  any  other  change,  is  spoken  of,  with  refer- 
ence to  its  effect  upon  cell  activity,  as  a  stimulus,  which  must,  as 
has  been  pointed  out,  influence  a  cell  in  one  of  two  ways  only,  i.e.,. 
by  exciting  or  inhibiting  activity,  although  there  may  be  first  an 
increase  and  later  a  suppression  of  activity.  Different  kinds  of 
cells  are  of  course  differently  affected  by  any  one  chemical  sub- 
stance, some  being  more  susceptible  to  it  than  others.  This  fact 
is  taken  advantage  of  in  medicine  by  the  administration  of  vari- 
ous drugs  with  the  purpose  of  increasing  or  diminishing  one  or 
another  form  of  cell  activity.  Thus  we  relieve  pain  with  mor- 
phine, suppress  consciousness  with  ether,  increase  the  secretions 


SURGICAL  PATHOLOGY  65 

in  the  intestinal  canal  with  cathartics,  etc.  Poison  is  therefore 
a  relative  term,  since  the  harmful  effect  of  a  substance  depends 
on  the  dosage  and  sometimes  on  other  factors.  Even  distilled 
water  is  a  deadly  poison  when  introduced  in  quantity  directly 
into  a  vein,  whereas  water  containing  from  six-  to  nine-tenths  of 
one  per  cent,  of  common  salt  (the  so-called  "normal"  salt  solu- 
tion so  much  used  in  surgery)  has  no  ill  effect. 

The  poisonous  substances  which  give  rise  to  disease  arise  from 
various  sources.  They  may  be  introduced  from  without,  as  with 
the  food  or  drink  or  with  the  inspired  air.  They  may  be  produced 
in  the  digestive  canal  by  the  fermentative  action  of  saprophytic 
bacteria.  Other  poisons  are  produced  within  the  tissues  of  the 
body  by  the  secretions  of  invading  pathogenic  microorganisms. 
The  disintegration  of  dead  tissue  cells,  such  as  result  from  burns 
or  other  injuries  or  from  disease,  gives  rise  to  poisonous  substances. 
Finally  the  body  may  be  poisoned  by  its  own  secretions,  either 
by  the  reabsorption  of  retained  excretions  or  by  excessive  activity 
of  certain  glands,  or  by  the  failure  of  the  cells  of  some  organ  to 
do  their  part  in  the  complex  chemical  changes  which  normally 
go  on  within  the  body. 

IV.  CHANGES  IN  CELL  ACTIVITIES 

The  many  kinds  of  cells  which  make  up  the  various  tissues 
and  organs  of  the  body  are  so  interrelated  in  their  activities  that 
it  rarely  if  ever  happens  that  one  set  of  cells  can  be  deranged  in 
their  action  without  effecting  changes  in  other  groups  throughout 
the  body.  The  normal  body  is  continually  adjusting  itself  to 
changes  in  its  environment,  and  the  altered  activities  of  cells 
which  occur  in  disease  are  very  often  of  the  same  kind  as  those  which 
occur  normally ;  i.e.,  the  organism  is  attempting  to  adjust  or  adapt 
itself  to  the  abnormal  situation,  but  in  the  case  of  a  diseased  con- 
dition with  only  partial  success.  Changes  such  as  these  may  be 
called  adaptive  changes  in  the  activities  of  the  body- cells. 

On  the  other  hand,  certain  groups  of  cells  may  be  directly 
stimulated  to  an  abnormal  activity  which  has  no  adaptive  quality. 
These  we  may  call  perverted  changes  in  cell  activity.  It  is,  how- 
ever, by  no  means  always  possible  to  distinguish  in  diseased 
conditions  between  adaptive  and  perverted  changes. 

1.  Adaptive  Changes. — These  are  very  numerous  in  patho- 
logical conditions,  and  it  is  of  the  greatest  importance  to  be  able 
to  understand  as  far  as  possible  their  significance. 
5 


66  THE  FIELD  OF  SURGERY 

Examples  of  Adaptive  Changes. — There  is  no  sharp  line  be- 
tween the  adaptive  changes  which  occur  in  health  and  in  disease. 
For  example,  the  flushed  face,  the  gasping  breath  and  the  quick- 
ened pulse  which  are  manifest  after  a  hard  run  or  other  muscular 
effort  are  adaptive  changes  which  are  seen  also  in  scarcely  altered 
form  in  such  a  disease  as  pneumonia  and  in  other  pathological 
conditions.  The  phenomena  which  accompany  an  attack  of  acute 
peritonitis  furnish  a  remarkable  example  of  the  organism  adapt- 
ing itself  to  an  abnormal  situation.  Infectious  material  intro- 
duced from  without  or  escaping  from  the  intestinal  tract  at  one 
locality  within  the  abdomen  would  be  rapidly  spread  throughout 
the  peritoneal  cavity  by  the  movements  of  the  intestinal  coils 
which  occur  normally  in  the  process  of  digestion,  and  by  the 
action  of  the  abdominal  muscles.  It  is  for  the  greatest  advantage 
to  the  organism  that  such  scattering  of  the  infectious  material 
should  be  prevented  and  that  it  should  be  confined  as  far  as 
possible  to  one  locality.  All  the  phenomena  which  appear  there- 
fore are  such  as  will  contribute  to  this  end.  The  muscular  walls 
of  the  intestines  are  paralyzed  and  motion  of  the  coils  ceases. 
Distention  with  gas  increases  the  fixation  of  the  intestinal  coils. 
The  abdominal  muscles  also  are  held  with  a  board-like  rigidity. 
Local  pain  and  tenderness  make  a  constant  and  imperative 
demand  upon  the  attention  to  insure  voluntary  effort  to  keep 
this  region  quiet.  If  food  is  taken  vomiting  ensues  to  prevent  its 
passage  into  the  intestinal  tract.  Locally  in  the  infected  region 
inflammation  is  inaugurated,  itself  a  notable  example  of  adaptive 
change  whereby  the  surrounding  coils  of  intestine  become  ad- 
herent and  the  infected  area  is  rapidly  walled  off  from  the  sur- 
rounding parts. 

Compensatory  changes  are  those  whereby  (a)  one  group  of 
cells  take  up  and  perform  the  work  of  other  cells  (of  the  same  or 
even  of  a  different  kind)  which  have  been  destroyed  or  whose 
function  has  been  impaired;  or  (b)  where  certain  cells  increase 
their  activity  in  response  to  a  special  need.  Thus  if  one  kidney 
is  removed  the  other  does  double  work  and  may  increase  in  size. 
If  the  spleen  is  removed  other  organs,  perhaps  the  lymph-nodes, 
take  up  its  work  and  the  animal  continues  in  health.  One  lung 
can  readily  do  the  work  of  two.  Hypertrophy  of  the  heart 
muscle  is  an  example  of  the  second  type  of  compensatory  change, 
being  adapted  to  overcome  increased  resistance  at  some  point  in 
the  circulation.  If  a  blood-vessel  is  obstructed  other  smaller 


SURGICAL  PATHOLOGY  67 

vessels  in  the  neighborhood  dilate  till  they  are  able  to  carry  the 
full  volume  of  blood,  forming  what  is  known  as  the  collateral 
circulation. 

Primary  adaptive  changes  occur  in  an  accidental  or  operative 
wound.  When  living  tissues  are  divided  by  a  wound  a  large 
number  of  blood-vessels  (arteries,  veins  and  capillaries)  are 
severed,  and  this  condition  calls  for  the  immediate  inauguration 
of  adaptive  changes,  which  to  be  effective  must  serve  two  ends: 
first,  to  check  the  escape  of  blood,  and,  second,  to  preserve  un 
impaired  the  flow  of  blood  to  the  tissues  which  the  severed 
vessels  originally  supplied.  The  first  end  is  accomplished  by 
changes  in  the  blood  resulting  in  what  is  known  as  clotting, 
whereby  the  fluid  blood  becomes  changed  into  a  firm  jelly  which 
plugs  the  vessels  and  checks  the  escape  of  fluid  blood.  This 
chemical  change  in  the  blood  is  a  very  complex  one  due  to  the 
giving  off,  from  cells  in  the  blood  and  from  tissue  cells,  of  certain 
substances  which  then  unite  with  another  substance  dissolved  in 
the  circulating  blood  to  form  the  fibrin  that  constitutes  the  clot. 
The  second  end  is  attained  by  the  compensatory  action  already 
referred  to,  i.e.,  the  dilatation  of  the  adjacent  vessels  to  carry 
on  the  blood  stream  into  the  area  to  which  its  flow  has  been  inter- 
rupted. These  two  adaptive  changes  are  essential  conditions 
for  the  success  of  operative  surgery.  Without  the  first  every 
wound  would  result  in  fatal  hemorrhage.  In  practice  it  is  neces- 
sary to  assist  nature  by  the  temporary  closing  of  the  larger  vessels 
by  means  of  clamp  and  ligature  until  the  clot  has  formed.  This 
means  of  checking  hemorrhage,  however,  is  by  itself  of  no  avail 
when,  as  happens  in  certain  individuals  (bleeders),  the  clotting 
adaptation  fails.  Without  the  second  adaptation  large  areas  of 
sloughing  tissue  would  result  from  every  extensive  wound.  Such 
sloughing  of  tissue,  more  or  less  extensive,  does  in  fact  occur  at 
times  as  the  result  of  injudicious  or  unavoidable  interference  with 
the  circulation  by  a  surgical  operation. 

Inflammation  is  defined  as  "the  condition  into  which  tissues 
enter  as  a  reaction  to  irritation"  or  injury.  It  is  an  adaptive 
reaction  of  the  greatest  interest  and  importance  which  can  only 
be  briefly  outlined  here.  The  process  can  be  actually  seen  at 
work  in  the  classical  experiment  of  placing  the  web  of  a  frog's 
foot,  or  a  portion  of  the  mesentery  drawn  out  of  the  abdomen, 
under  the  lens  of  the  microscope,  and  irritating  the  surface  of 
the  tissue  by  a  slight  scratch  (Figs.  25  and  26).  Through  the 


68 


THE  FIELD  OF  SURGERY 


thin  transparent  membrane  the  arteries,  veins,  and  capillaries 
can  be  clearly  seen  with  the  blood  stream  flowing  through  them. 
The  pulsating  stream  through  the  arteries  is  distinguishable,  and 
the  continuous  flow  through  veins  and  capillaries.  In  the  capil- 
laries the  individual  blood-cells  or  corpuscles  can  be  seen  as  they 
pass  in  single  file,  but  in  the  larger  vessels  these  are  seen  only  as 
a  swiftly  moving  mass.  The  first  change  observed  as  the  result 

FIG.  25.  Fio.  26. 


Frog's  mesentery,  normal. 


Frog's  mesentery,  inflamed. 


FIGS.  25  and  26. — a,  small  vein;  bb,  dd,  nerve-fibres;  c,  capillary;  ee,  connective  tissue 
(in  Fig.  12  filled  with  migrating  leucocytes).      (Agnew.) 

of  the  irritation  is  a  dilatation  of  the  vessels  with  a  more  rapid 
flow  of  the  blood  stream;  later  the  rapidity  of  the  flow  is  dimin- 
ished and  in  places  it  becomes  actually  stagnant,  with  an  occa- 
sional backward  and  forward  motion  of  the  mass  of  free  blood - 
cells.  Through  the  thin  walls  of  the  capillaries  there  is  an  escape 
of  the  fluid  part  of  the  blood  which  distends  the  spaces  in  the 
tissues  between  the  blood-vessels.  The  cells  of  the  blood,  red 
and  white,  particularly  the  leucocytes,  also  make  their  way 
through  the  capillary  walls  and  wander  free  in  the  tissue  inter- 


SURGICAL  PATHOLOGY 


69 


spaces  (Fig.  27).  Later  (this,  however,  is  not  readily  visible  in 
the  living  tissue)  the  local  connective-tissue  cells  have  their 
reproductive  power  stimulated,  new  ceils  are  produced  and  new 
capillary  blood-vessels  are  formed. 

These  changes  seen  in  the  frog's  mesentery  under  the  micro- 
scope readily  explain  the  familiar  phenomena  of  inflammation, 
with  its  cardinal  signs  of  heat,  redness,  swelling  and  pain,  as 
seen  on  the  surface  of  our  own  bodies,  for  example  in  a  boil. 
The  redness  of  the  skin  and  the  local  heat  are  due  to  the  dilatation 
of  the  vessels  and  the  consequent  increased  flow  of  blood  to  the 
part,  while  the  swelling  and  pain  are  due  to  the  great  distention 
of  the  tissue  interspaces  with  the  inflammatory  exudate.  When 


FIG.  27. — Emigration  of  leucocytes.     The  arrow  shows  direction  of  blood-current.     (F. 

C.  Wood,  M.D.) 

mechanical  injury  alone  is  present,  uncomplicated  by  bacterial 
invasion,  the  inflammatory  reaction  is  relatively  slight  and  under 
these  conditions  identical  with  the  first  stages  of  the  healing 
process,  to  be  presently  described,  whereby  repair  of  the  injured 
tissue  is  effected.  When,  however,  septic  bacteria  have  found 
lodgement  in  the  injured  tissues  the  reaction  becomes  greatly 
intensified;  the  amount  of  the  exudate,  both  fluid  and  cellular, 
is  largely  increased,  constitutional  symptoms,  including  fever  and 
other  disturbances,  appear,  and  the  role  of  these  adaptive  changes 
becomes  extended  beyond  the  mere  repair  of  the  injury  to  an 
active  defence  against  the  action  of  the  invading  bacteria. 

The  Healing  Process. — The  reaction  by  which  injured  tissues 
are  repaired  and  the  loss  of  tissue  restored  is  an  adaptation  of 


70  THE  FIELD  OF  SURGERY 

vital  importance  to  the  organism  and  one  that  is  almost  constantly 
going  on  in  some  part  of  the  body,  as  in  the  familiar  rapid  healing 
of  superficial  cuts  and  abrasions  on  the  surface  of  the  skin.  It 
may  therefore  be  considered  a  normal  process  when  uncomplicated 
by  conditions  which  retard  it,  such  as  infection.  It  is  a  highly 
efficient  process  within  certain  limits,  but  these  limits  are  rather 
sharply  defined.  In  general  it  may  be  said  that  only  the  sim- 
pler tissues  are  capable  of  restoration  by  the  healing  process. 
Highly  differentiated  cells  of  complex  function,  such  as  those 
of  the  central  nervous  system  and  the  muscles,  are  incapable  of 


FIG.  28. — Section  through  skin  of  guinea-pig  eight  hours  after  a  wound:  a,  the  wound, 
filled  with  clot,  the  capillaries  thrombosed  on  both  sides;  round-cell  infiltration;  be,  sweat- 
gland;  d,  hair-follicle.  (Shakespeare.) 

restoration.  When  such  cells  which  are  incapable  of  restoration 
have  been  destroyed  the  gap  is  filled  by  new  connective  tissue, 
forming  what  is  known  as  a  scar.  Healing  is  more  rapid  in  the 
young  than  in  the  old,  and  in  individuals  with  impaired  health 
the  process  may  be  more  or  less  retarded.  We  will  consider 
briefly  what  takes  place  in  the  healing  of  a  wound. 

The  earlier  steps  of  the  process  are  those  which  have  been 
described  under  inflammation. 

Whenever  any  tissue  of  the  body  has  been  wounded,  the 
injury  acts  as  a  stimulus  upon  the  cells  of  the  part,  calling  into 
activity  certain  of  their  faculties,  principally  those  of  reproduction 


SURGICAL  PATHOLOGY 


71 


and  of  motion.  Several  varieties  of  cells  are  thus  set  to  work  in 
the  reparative  process.  The  most  active  part  appears  to  be 
taken  by  the  connective-tissue  cells,  whose  function  it  is  to 
build  up  everywhere  the  solid  framework  of  the  body.  The 
cells  which  form  the  capillary  blood-vessels  and  the  epithelial 
cells  of  the  skin  participate  in  the  process,  as  do  also  in  another 
way  the  free-moving  white  cells  of  the  blood,  or  leucocytes. 

The  first  thing  that  happens  is  a  temporary  cementing  or 
gluing  together  of  the  wound  surfaces  by  the  coagulated  fibrin 
formed  by  the  blood  which  oozes  from  the  divided  capillaries 
(Fig.  28).  The  connective-tissue  cells  on  each  side  multiply 


FIG.  29. — The  same  at  a  later  stage.  The  clots  on  the  capillaries  almost  removed,  new 
vessels  forming  towards  the  gap,  new  connective-tissue  spindle-cells  replacing  the  round 
cells.  The  epithelium  has  united  on  the  surface.  (Shakespeare.) 

by  division,  closing  in  the  space  between  the  wound  surfaces 
with  an  interlacing  mass  of  new  cells.  The  cells  which  form  the 
walls  of  the  capillary  blood-vessels  increase  in  number,  and  loops 
of  new-formed  capillaries  push  across  the  gap  to  unite  with 
similar  loops  from  the  opposite  side  (Fig.  29).  The  epithelial 
cells  of  the  skin  also  have  their  reproductive  powers  awakened, 
though  somewhat  more  slowly,  new  cells  being  formed  which 
bridge  the  incision  at  the  surface  (Fig.  30).  Meantime,  beginning 
almost  from  the  moment  of  the  injury,  the  leucocytes  are  stim- 
ulated to  more  active  motion  and  are  attracted  in  large  numbers 
to  the  wounded  area,  By  virtue  of  their  so-called  power  of 


72 


THE  FIELD  OF  SURGERY 


amoeboid  movement,  they  force  their  way  through  the  walls  of 
the  smaller  blood-vessels  and  into  the  tissue  spaces  (Fig.  27)  in 
the  vicinity  of  the  injury,  where  they  exercise  their  "phagocytic" 
power  to  eat  up  and  carry  away  fragments  of  dead  tissue  cells 
and  other  debris,  including  the  fibrin  which  provisionally  ce- 
mented the  wound  surfaces  and  even  bacteria  or  other  alien  cells, 
if  any  have  found  their  way  into  the  wound.  The  secretions  of 
the  leucocytes  also  digest  and  liquefy  the  dead  matter  in  the 
wound,  and  the  absorption  of  fluid  material  passing  into  and 
carried  away  by  the  blood  stream  aids  in  the  process  of  cleaning 


Fia.  30. — The  same  later.     The  gap  filled  with  new  connective  tissue  and  young  blood- 
vessels (Shakespeare). 

up.  By  the  end  of  the  third  to  the  fifth  day  the  divided  tissues 
are  practically  reunited  and  there  remains  only  to  be  accomplished 
the  slower  process  of  the  formation  of  intercellular  substances 
by  the  connective-tissue  cells  to  consolidate  the  scar  (Fig.  31). 

Healing  by  granulation  so  called  occurs  where  an  open  wound 
with  widely  separated  edges  is  filled  up  with  new-formed  tissue 
(Fig.  32).  The  process  is  essentially  the  same  only  with  a  more 
extensive  formation  of  new  tissue  and  a  much  slower  accomplish- 
ment. 

Defences  of  the  Body  Against  Infection. — When  an  infection 
occurs  a  series  of  reactions  within  the  body  is  inaugurated  varying 


SURGICAL  PATHOLOGY  73 

with  the  character  of  the  infection  itself  and  also  with  other 
factors,  such  as  the  locality  of  the  invasion  and  the  powers  of 
resistance  of  the  individual.  These  reactions  are  partly  adaptive, 
tending  to  protect  the  body  from  harm  and  to  aid  in  its  restora- 
tion to  a  normal  condition,  and  partly  also  due  to  altered  cell 
activities  which  have  no  adaptive  quality.  The  weapons  of  attack 
of  the  invading  cells  are  chemical  in  nature.  It  is  by  the  poisonous 
products  of  the  invaders  that  the  tissue  cells  are  injured.  These 
harmful  chemical  products  produced  by  the  invading  cells  are 


Fio.  31. — Cicatrix  formed  in   the  wound,   the  young  blood-vessels  having  disappeared 

(Shakespeare). 

of  several  kinds;  for  example:  (1)  poisonous  secretions  extruded 
by  the  infecting  cells  known  as  toxins;  (2)  ferments  or  enzymes 
which  have  the  power  of  disintegrating  and  dissolving  living  and 
dead  tissue  cells;  (3)  poisonous  products  resulting  from  the  dis- 
integration of  dead  tissue  cells  or  dead  cells  of  the  infecting 
organism. 

The  symptoms  or  manifestations  of  infectious  disease,  the 
high  fever,  the  chills,  the  digestive  and  nervous  disturbances, 
the  weakness  and  rapid  emaciation,  and  sometimes  the  local 
signs  of  inflammation  indicate  a  very  profound  derangement  of 


74 


THE  FIELD  OF  SURGERY 


the  normal  functions  of  the  body.  Even  to  the  most  superficial 
observation  there  is  a  suggestion  of  a  struggle  between  the  disease 
and  the  forces  that  tend  toward  health,  or,  to  speak  more  defi- 
nitely, between  the  cells  of  the  body  and  the  invading  cells.  The 
very  fact  that  recovery  ever  takes  place  at  all  is  in  itself  conclusive 
evidence  of  such  a  struggle.  What,  then,  are  the  means  of 
defence  which  the  cells  of  the  body  are  able  to  employ  against 
the  invaders? 


FIQ.  32. — Healing  of  a  wound  by  granulation:  a,  layer  of  fibrin,  leucocytes,  and  detri- 
tus over  surface  of  granulations;  6,  advancing  edge  of  epidermal  cells  from  skin;  c,  skin  at 
edge  of  wound;  d,  corium  with  some  inflammatory  infiltration;  e,  blood-vessel  in  normal 
tissue  differing  in  its  structure  from  those  in  the  granulation  tissue;  /,  blood-vessel  in  latter 
with  a  leucocyte  emigrating  through  its  walls;  g,  new  connective-tissue  cells,  called  fibro- 
blasts;  h,  points  to  an  epithelial  cell,  and  on  the  other  side  of  h  are  two  cells  in  process  of 
division,  showing  their  rapid  growth.  (F.  C.  Wood,  M.D.) 

These  appear  to  be  of  two  kinds:  (1)  those  by  which  the  alien 
cells  are  destroyed  or  their  growth  is  checked,  and  (2)  those  by 
which  the  poisonous  products  of  the  infecting  organisms  are 
neutralized  and  rendered  harmless.  Thus  the  body-cells  possess 
both  offensive  and  defensive  weapons  in  their  battle  with  the 
invading  enemies.  There  are  two  ways  in  which  the  infecting 
cells  may  be  destroyed  after  they  have  entered  the  body.  One 
is  through  the  presence  in  the  blood  of  substances  which  are 
poisonous  to  them.  Such  substances  are  normally  present  in 


SURGICAL  PATHOLOGY 


75 


the  blood;  they  are  the  result  of  chemical  activities  of  the  body- 
cells,  and  there  is  evidence  that  they  are  produced  in  increased 
amount  as  a  result  of  the  presence  of  the  infection. 

The  invading  cells  may  also  be  killed  by  the  direct  attack 
upon  them  of  certain  of  the  cells  of  the  body,  which  literally 


Fio.  33. — Varieties  of  colorless  blood-cells  seen  in  normal  human  blood:  a,  small  lym- 
phocytes; 6,  large  lymphocyte  or  mononuclear  leucocyte;  c,  transitional  leucocyte;  d, 
polymorphonuclear  leucocytes;  e,  eosinophile;  /,  red  cells.  X  900. 

seize  and  devour  them.  Beside  the  highly  specialized  fixed  cells 
which  make  up  the  various  tissues  and  organs  of  the  body,  there 
are  other  cells  which  are  not  fixed,  but  detached  and  free,  and 


r 


i 


L 


J 


FIG.  34. — Amoeba  coli  (Entamoeba  dysenteries),  common  form.     X  400. 

are  carried  about  in  the  ceaselessly  flowing  blood  stream.  These 
cells  are  of  two  kinds  which  exhibit  a  remarkable  contrast  in  the 
character  of  their  activities  (Fig.  33).  The  red  corpuscles  of 
the  blood  are  perhaps  the  most  highly  specialized  of  all  the  cells 
of  the  body.  They  can  do  one  thing  only,  take  up  oxygen  from 


76  THE  FIELD  OF  SURGERY 

the  air  and  carry  it  to  the  tissue  cells.  They  have  lost  all  the 
other  powers  of  the  cell  and  even  the  most  essential  part  of  the 
cell  structure,  the  nucleus.  On  the  other  hand,  the  white  cells 
of  the  blood,  or  " leucocytes,"  appear  to  be  the  least  differentiated 
and  specialized  of  any  of  the  cells.  They  retain  all  the  activities 
that  single-celled  organisms  possess.  In  their  appearance  and 
behavior  they  strikingly  resemble  certain  forms  of  unicellular 
organisms  known  as  amoebae  (Fig.  34)  which  are  found  in  stagnant 
water.  These  organisms  have  a  peculiar  method  of  movement, 
by  a  process  of  thrusting  out  a  portion  of  the  protoplasm  of  the 
cell  body  and  of  enclosing  particles  of  food  material  which  then 
become  digested  and  dissolved.  The  cell  folds  itself  about  a 
solid  particle  of  food  material,  much  as  one  may  wrap  a  piece 
of  putty  about  a  pea.  Around  the  food  particle  within  the  cell 
body  there  then  forms  a  small  cavity  or  vacuole,  into  which  there 
is  apparently  secreted  from  the  cell  protoplasm  digestive  juices 
which  dissolve  the  food  and  prepare  it  to  be  assimilated.  With 
reference  to  this  faculty  such  cells  are  designated  by  a  name  which 
signifies  " cells  that  eat."  They  are  called  " phagocytes"  (Fig. 
35).  The  leucocytes  possess  this  same  power  of  amoeba-like  or 
amoeboid  movement;  and  it  is  a  part  of  their  normal  activities 
to  take  up  and  dispose  of  dead  and  waste  and  foreign  material 
in  the  blood  stream  and  tissue  interspaces,  and  when  infection 
takes  place  they  exercise  this  phagocytic  power  upon  the  invading 
cells.  They  thus  take  up  and  destroy  both  dead  and  living 
bacteria  and  other  organisms.  This  form  of  activity  of  the 
leucocytes,  known  as  phagocytosis,  is  in  many  cases  heightened 
during  infection  as  a  result  of  stimuli  brought  to  bear  upon  them, 
directly  or  indirectly,  through  the  presence  of  the  alien  cells. 
There  is  a  close  relation  between  these  two  offensive  means  which 
the  body-cells  employ  against  infection,  and  together  they  play 
a  most  important  part  in  the  struggle. 

Another  of  the  defensive  activities  of  the  body-cells  is  the 
formation  of  antitoxins,  which,  as  we  have  indicated,  do  no 
harm  to  the  infecting  organisms,  but  render  them  harmless  by 
neutralizing  their  poisonous  secretions  or  toxins.  The  formation 
of  antitoxin  is  also  an  example  of  the  use  of  certain  normal  activi- 
ties of  the  body-cell  as  a  means  of  defence  against  infection. 
A  beautiful  explanation  of  this  is  furnished  by  the  celebrated 
side-chain  theory  of  Ehrlich.  In  the  process  of  nutrition  the 
cell  must  first  seize  upon  the  ultimate  particles  or  molecules  of 


SURGICAL  PATHOLOGY 


77 


food  substances  and  fix  them  to  the  cell,  later  incorporating 
them  into  the  cell  substance  through  chemical  changes.  It  must 
be  remembered  that  we  are  here  dealing  with  the  ultimate 
chemical  structure  of  cell  substance,  which  is  infinitely  below 
the  limits  of  visibility.  The  actual  manner  of  fixation,  therefore, 
we  cannot  know,  but  must  picture  it  to  our  minds  in  a  somewhat 
crude  mechanical  form. 


i.oo 


1.20 


<^r 

1.05 


1.25 


1.10 


2.00 

Pigment  has 
ceased  moving. 


1.30 


2.10 
Outline  lost. 


1.15 


Fia.  35. — Phagocytosis.  Destruction  of  a  plasmpdium  malarise  by  a  leucocyte  in 
human  blood.  The  figures  indicate  the  time  of  observation,  the  whole  process  lasting  1  hour 
and  25  minutes.  (F.  C.  Wood,  M.D.) 

We  may  thus  think  of  the  molecules  which  make  up  the  cell 
protoplasm  as  possessing  little  rods  or  chains  projecting  from 
their  sides,  each  furnished  at  the  end  with  a  locking  device  of  a 
certain  shape  exactly  fitting  a  corresponding  locking  device 
attached  to  the  molecule  of  food  substance.  To  use  a  homely 
illustration,  it  is  as  if  the  two  were  supplied  with  a  set  of  hooks 
and  eyes  of  a  special  pattern.  These  side  chains  of  the  cell 
molecule  are  called  receptors,  or,  to  indicate  their  function  of 


78  THE  FIELD  OF  SURGERY 

fixing  nutritious  substances  to  the  cell,  nutrireceptors.  Now 
the  toxin  molecule  is  peculiar,  in  that  it  has  a  locking  device  of 
exactly  the  same  shape  as  that  of  some  variety  of  food  molecule ; 
its  eye  fits  the  nutrireceptor's  hook,  but  the  rest  of  its  structure 
is  wholly  different  from  that  of  the  food  molecule.  It  is  not 
only  unavailable  as  food,  but  it  is  a  deadly  poison  to  the  cell. 
When  a  toxin  molecule  has  once  become  fixed  to  a  receptor  they 
cannot  be  separated,  but  the  cell  has  one  way  left  of  getting  rid 
of  its  dangerous  incumbrances.  It  breaks  off  and  sets  free  the 
receptors  to  which  toxin  molecules  are  attached.  New  receptors 
are  then  formed  to  take  the  place  of  those  lost,  and,  by  a  well- 
known  law  of  nature's  bounty,  they  are  formed  in  great  excess 
over  those  lost.  Many  of  the  over-abundant,  new-formed  recep- 
tors are.  crowded  off  and  become  free  in  the  blood  stream.  Here 
they  encounter  and  fix  the  free  toxin  molecules  before  they  have 
had  time  to  reach  the  cells,  thus  rendering  them  harmless.  These 
free  and  detached  receptors  in  the  blood  form  what  we  know  as 
antitoxin. 

In  all  that  we  know  about  its  powers  of  resistance  against 
disease,  there  is  nothing  to  suggest  that  the  body  is  supplied 
with  a  special  defensive  mechanism  designed  or  adapted  for 
that  purpose  alone.  What  happens  is  that  the  cells  are  stimulated 
by  the  invaders  to  increase  (or  sometimes  to  decrease)  certain 
activities  that  they  are  constantly  exercising  in  the  condition  of 
health,  activities  of  motion,  of  reproduction,  or  of  chemical 
change,  such  as  are  normally  concerned  with  the  nutrition  of 
the  cell  or  with  its  oxidating  or  secreting  power. 

Perverted  Activities  of  Cells. — These  are  those  which  are 
due  to  the  direct  effect  of  abnormal  stimuli  exciting  the  cells  to 
activity  which  has  no  adaptive  uses.  Notable  examples  are  the 
convulsive  seizures  in  tetanus  and  poisoning  by  strychnia.  The 
thyroid  gland  is  excited  to  over-activity  (hypersecretion)  in 
exophthalmic  goitre  (Graves's  disease).  In  other  cases  its 
activity  is  depressed  (hyposecretion),  as  in  myxcedema.  The 
formative  or  reproductive  activities  of  cells  are  apparently  per- 
verted in  the  case  of  rapidly  growing  tumors,  particularly  of  the 
malignant  type,  and  the  same  is  true  in  certain  infectious  diseases, 
notably  syphilis  and  tuberculosis,  where  there  occurs  a  rapid 
proliferation  of  cells  (hyperplasia)  associated  with  degenerative 
changes. 


SURGICAL  PATHOLOGY  79 

V.  TISSUE  CHANGES 

Activities  of  cells  are  of  three  kinds:  (1)  functional,  (2)  nutri- 
tive, (3)  formative  or  reproductive.  Increase  or  diminution  of 
formative  activities  gives  rise  to  tissue  changes  varying  from 
microscopical  lesions  to  gross  anatomical  alterations. 

1.  Constructive  Tissue  Changes. — We  have  already  con- 
sidered the  constructive  changes  involved  in  the  process  of  heal- 
ing or  repair.  Other  examples  of  constructive  change  are  seen 
in  hypertrophy  and  in  the  formation  of  tumors. 

Hypertrophy. — Simple  hypertrophy  is  an  increase  in  the  size 
of  individual  cells.  Numerical  hypertrophy  is  an  increase  in 
the  number  of  cells  of  a  part  (hyperplasia) .  Examples  of  normal 
or  physiological  hypertrophy  are  seen  in  the  uterus  in  pregnancy, 
in  the  breasts  in  laceration,  and  in  the  growth  of  muscles  by 
exercise;  adaptive  hypertrophy  in  the  increase  of  the  heart 
muscle  when  called  upon  for  continuous  extra  work  from  any 
cause,  such  as  imperfection  in  the  valves  of  the  heart.  When 
a  part  of  the  intestine  is  constricted  for  a  long  time,  as  by  a 
tumor,  the  muscular  coats  of  the  intestine  above  the  constriction 
hypertrophy.  Compensatory  hypertrophy  is  seen,  for  example, 
when  one  kidney  enlarges  following  the  destruction  by  disease 
or  the  surgical  removal  of  the  other  kidney.  It  has  already  been 
indicated  that  intermittent  pressure  may  cause  hypertrophy,  as 
in  ''corns "  and  calluses.  Irritation  by  abnormal  chemical  sub- 
stances circulating  in  the  blood  may  give  rise  to  overgrowth  of 
cells,  particularly  in  some  of  the  infections. 

Tumors,  or  new-growths,  are  among  the  most  important 
conditions  in  the  human  body  which  are  amenable  to  surgical 
treatment. 

The  formation  of  a  tumor  is  due  to  the  increased  growth  of 
some  of  the  cells  in  that  part  of  the  body  where  the  tumor  origi- 
nates, under  the  action  of  stimuli  the  character  and  origin  of 
which  are  unknown.  Two  of  the  cell  faculties  are  concerned, 
their  reproductive  power  and  their  power  to  form  those  inter- 
cellular substances  of  which  all  the  solid  parts  of  the  body  are 
composed.  We  divide  all  tumors  into  two  classes,  known  as 
benign  and  malignant.  In  the  case  of  the  benign  tumors  some- 
thing like  the  normal  balance  between  the  reproduction  of  cells 
and  the  formation  of  intercellular  substance  is  preserved;  in 
other  words,  the  cells  behave  like  the  normal  mature  cells  of  the 
part.  The  result  is  that  the  new-growth  resembles  normal 


80  THE  FIELD  OF  SURGERY 

tissue  to  some  extent,  the  tumor  increases  slowly  in  size,  the 
formation  of  intercellular  substances  fixes  the  cells  in  the  part 
so  that  there  is  no  tendency  for  them  to  infiltrate  the  surrounding 
tissues  or  for  loose  cells  to  be  carried  away  through  the  lymphatics 
or  blood  stream  to  start  new  tumors  in  other  parts  of  the  body 
(metastases) .  Such  tumors  usually  have  sharply  defined  borders. 
They  do  not  tend  to  recur  after  removal,  and  their  presence 
does  little  harm. 

In  the  case  of  the  malignant  tumors,  on  the  other  hand,  all 
the  energies  of  the  cells  are  devoted  to  the  exercise  of  their  repro- 
ductive power;  the  new  cells  show  little  or  no  tendency  to  the 
formation  of  intercellular  substances  or  to  grow  to  the  mature 
form  of  the  normal  cells.  These  tumors  therefore  do  not  resemble 
any  normal  tissue.  The  cells  are  not  fixed,  and  tend  to  infiltrate 
the  surrounding  tissues  and  to  be  carried  to  distant  parts  of  the 
body,  to  start  new  tumors  there.  They  invariably  cause  the  death 
of  the  patient,  usually  within  a  time  varying  from  a  few  months 
to  two  or  three  years.  There  are  two  types  of  malignant  tumors 
— one  (sarcoma)  in  which  the  connective-tissue  cells  are  the  ones 
concerned,  and  one  (carcinoma  or  cancer)  in  which  the  epithelial 
cells,  such  as  form  the  skin  and  secreting  glands,  are  involved. 
The  only  hope  of  cure  lies  in  early  and  complete  removal. 

2.  Destructive  Tissue  Changes. — Atrophy  is  the  opposite  of 
hypertrophy,  a  wasting  away  of  cells  or  tissues.  Atrophy  occurs 
as  a  normal  adaptive  change  in  involution  of  the  uterus  following 
parturition.  Just  as  cells  increase  in  size  as  a  result  of  active 
exercise  of  their  functions,  so  as  a  result  of  disuse  they  shrink 
away.  A  limb  fixed  in  a  plaster  cast  rapidly  diminishes  in  size 
from  wasting  of  the  muscles,  and  the  same  is  true  of  muscles 
paralyzed  by  section  of  a  motor  nerve.  Atrophy  resulting  from 
pressure  has  been  mentioned.  A  diminished  supply  of  nourish- 
ment is  a  cause  of  atrophy,  both  local  and  general,  as  seen  in 
starvation,  and  so  also  is  malnutrition  due  to  the  inability  to 
utilize  food  material  properly,  as  in  many  wasting  diseases. 

Necrosis  means  the  death  of  cells.  In  the  normal  body  many 
cells  are  constantly  perishing  when  their  usefulness  is  ended,  this 
being  particularly  true  of  the  cells  of  the  blood,  red  and  white, 
and  of  the  epithelial  cells  which  clothe  the  body  surface.  All  of 
these  are  as  constantly  replaced  by  new  cells.  The  .causes  of 
pathological  cell  death  are  either  toxic  or  nutritional,  i.e.,  by 
the  action  of  poisons  or  by  the  deprivation  of  nourishment. 


SURGICAL  PATHOLOGY  81 

Trauma,  extreme  degrees  of  heat  and  cold,  and  active  chemicals 
such  as  strong  acids  and  alkalies  are  direct  causes  of  cell  death. 
The  toxins  of  infectious  diseases,  such  as  typhoid  and  diphtheria, 
circulating  in  the  blood,  cause  necrosis  of  small  groups  of  cells 
here  and  there  in  the  liver  and  other  organs;  this  being  known  as 
focal  necrosis.  It  is  found  also  in  severe  cases  of  septic  disease. 
In  local  areas  of  septic  infection  more  or  less  extensive  necrosis 
of  cells  always  occurs,  large  sloughs  sometimes  forming  as  in 
carbuncles.  Depriving  the  tissues  of  the  circulating  fluids  which 
normally  bathe  them  is  followed  by  death  of  the  local  cells  within 
a  few  hours.  The  effect  of  continued  pressure  has  been  referred 
to  as  a  cause  of  sloughing,  a  fact  which  should  be  borne  in  mind 
in  applying  bandages  and  splints.  Gangrene  is  the  death  of 
large  areas  or  whole  parts  of  the  body,  such  as  the  extremities, 
and  is  due  either  to  cutting  off  entirely  the  arterial  supply  of 
blood  or  to  obstructing  the  return  of  the  blood  through  the  veins, 
as  by  a  tight  bandage  about  a  limb.  Certain  constitutional 
diseases,  such  as  diabetes,  and  also  the  cutting  off  of  the  normal 
nerve  supply  to  the  part  predispose  to  gangrene. 

3.  Cell  Degenerations. — Perverted  nutrition  of  cells  gives  rise 
to  changes  known  as  degenerations.  Albuminous  materials 
(proteids);  carbohydrates  (starches  and  sugars);  fats;  certain 
salts  and  water  are  the  materials  entering  into  cell  nutrition. 
The  degenerative  changes  connected  with  each  of  these  can  only 
be  briefly  mentioned  here.  Many  of  them  are  named  from  a 
fancied  resemblance  to  familiar  substances.  Thus  among  the 
degenerations  concerned  with  the  proteid  elements  of  nutrition 
we  have  waxy  or  amyloid  (starch-like)  degenerations;  hyaline 
(glass-like);  mucoid  (mucus-like);  caseous  (cheese-like);  and 
colloid  (gum-like)  degenerations.  Fatty  degeneration,  with 
deposit  of  minute  fat  globules  in  the  cell  body,  occurs  associated 
with  damaged  cell  activity  in  many  conditions.  Carbohydrates 
taken  with  the  food  are  stored  in  the  body,  for  use  in  the  produc- 
tion of  energy,  in  the  form  of  glycogen,  called  animal  starch,  and 
degenerative  changes  in  certain  cells  are  associated  with  loss  of 
balance  in  the  utilization  of  this  material.  Excessive  deposits 
of  lime  and  other  salts  in  cell  bodies  and  intercellular  substances 
constitute  what  is  known  as  calcareous  degeneration.  Akin  to 
this  perhaps  is  the  deposit  of  the  same  materials  in  ducts  and 
passages  of  the  body,  forming  so-called  calculi  or  stones  in  various 
organs,  the  urinary  bladder,  the  gall-bladder,  and  the  kidney. 
6 


82  THE  FIELD  OF  SURGERY 

VI.  DISTURBANCES  OF  GENERAL  FUNCTION 

As  a  result  of  these  pathological  changes  in  the  functional, 
nutritional  and  formative  activities  of  the  body-cells  there  neces- 
sarily follow  far-reaching  changes  in  the  general  function  of  the 
body  as  a  whole.  All  the  great  systemic  divisions  of  the  body  are 
involved  in  varying  degrees,  the  digestive,  vascular,  respiratory, 
glandular,  muscular  and  nervous  systems.  These  disturbances, 
arranging  themselves  into  various  groups  or  complexes,  according 
to  the  nature  of  their  origin,  constitute  the  symptoms  of  disease, 
and  the  study  of  these  together  with  the  local  changes  which 
accompany  them  is  what  is  known  as  clinical  (bedside)  medicine 
and  surgery. 


CHAPTER  V 
SURGICAL  AND  GYNECOLOGICAL  NOMENCLATURE 

IT  is  probable  that  no  branch  of  her  studies  offers  more 
constant  and  troublesome  confusion  to  the  student  nurse  than 
do  the  accumulation  and  proper  comprehension  of  her  profes- 
sional vocabulary.  And,  the  medical  nomenclature  being  de- 
rived from  single  and  combined  Greek  and  Latin  words,  this 
statement  is  particularly  applicable  to  those  who  have  not 
included  a  groundwork  in  the  "  dead  languages  "  as  part  of  their 
preliminary  education. 

It  will  be  the  effort,  in  this  chapter,  to  present  the  methods 
of  derivation  and  construction  in  such  a  light  that  the  student 
will  quickly  comprehend  their  application;  will  readily  assimilate 
the  more  usual  forms;  and  will  (it  is  hoped)  be  so  stimulated  in 
her  interest  in  this  line  of  work  that  she  will  feel  as  lost  without 
her  dictionary  as  without  her  thermometer  or  hypodermic 
syringe.  In  other  words,  the  object  will  be  not  to  supplant  the 
dictionary,  but  to  so  supplement  it  that  its  use  will  be  a  matter 
of  pleasant  investigation  rather  than  of  tedious  memorizing. 

It  would,  of  course,  be  far  beyond  the  possibilities  of  a  single 
chapter  to  even  approximately  supply  the  vocabulary  contained 
in  even  the  smallest  of  medical  dictionaries.  When,  however, 
once  a  comparatively  small  list  of  root-words,  prefixes  and  suffixes 
has  been  mastered,  their  methods  of  combination  understood, 
and  the  resulting  words  (broad  in  meaning,  but  simple  and  regular 
in  construction)  observed,  the  nurse  will  be  in  a  position  to 
build  up  most  of  the  routine  words  for  herself — or  at  least  to 
"  unbuild  "  those  with  which  she  comes  in  contact  into  their 
easily  recognizable  component  parts. 

General  Derivation. — It  may  be  generally  accepted  that  all 
strictly  medical  words  are  either  Latin,  Greek,  or  a  combination 
of  the  two.  The  facts  that  the  earliest  traditions  of  medicine, 
as  a  science,  are  founded  in  Greece  and  that,  at  a  later  day, 
Latin  was  the  universal  language  of  educated  and  scientific 
people,  easily  explain  this  great  preponderance  of  terms  from 
the  "  dead  languages." 

Method  of  Construction. — The  entire  medical  vocabulary 
may,  broadly  speaking,  be  considered  as  composed  of  root- 

83 


84  THE  FIELD  OF  SURGERY 

words — either  alone  or  in  combination  with  prefixes  or  suffixes, 
or  both.  The  root- word  may  generally  be  considered  as  describing 
some  definite  object,  as  (perhaps)  one  of  the  organs  of  the  body. 
The  prefix  usually  describes  some  variation  from  the  normal 
or  defines  the  relation  of  the  root-word  to  its  environment  or  of 
another  object  to  the  root- word.  The  suffix  generally  describes 
some  condition  of,  or  act  performed  upon,  the  root-word. 

Root=words. — The  medical  vocabulary  being,  as  already 
indicated,  derived  from  both  Greek  and  Latin,  it  is  not  surprising 
that  we  frequently  find  two  (and  even  three)  words  meaning 
the  same  thing.  In  such  cases,  we  may  have  the  common  name, 
the  Greek  scientific  name  and  the  Latin  scientific  name,  all  in 
frequent,  though  not  necessarily  interchangeable,  use.  In  these 
cases  it  will,  generally,  be  found  that  either  the  English  or  the 
Latin  word  is  used  in  speaking  directly,  by  name,  of  the  object 
and  the  Greek  root-word  in  those  compound  words  that  are  so 
common  throughout  the  medical  vocabulary.  For  instance,  we 
have  the  English  word,  womb,  the  Latin  word,  uterus,  and  the 
Greek  words,  hystera  and  metra,  referring  to  the  same  organ. 
The  English  word  is  the  one  in  common,  or  vernacular,  usage; 
the  Latin  is  the  one  in  regular,  unmodified  medical  usage;  and 
one  or  other  of  the  Greek  roots  is  regularly  found  in  the  compound 
forms.  Occasionally  but  one  root-word  is  in  use;  in  other  cases, 
they  are  both  present,  but  identical;  and,  less  frequently,  they 
are  present,  different  and  used  interchangeably.  In  the  last 
case,  however,  it  is  generally  true  that  the  Greek  root  would  be 
preferably  and  more  correctly  used.  In  the  present  listing  of 
those  root-words,  a  classification  by  systems  will  be  made  and, 
where  both  Latin  and  Greek  roots  are  used,  in  the  forming  of 
compound  words,  both  will  be  given. 

Respiratory  System: 

Nose  L.  naso-  G.  rhino- 
Tonsil  L.  tonsillo-                         G.  amygdalo- 
Larynx                                                                           G.  laryngo- 
Trachea                                                                       G.  tracheo- 
Bronchus                                                                     G.  broncho- 
Lung  L.  pulmo                           G.  pneumo- 

Digestive  System: 

Mouth  G.  stomato- 

Pharynx  G.  pharyngo- 

(Esophagus  G.  esophago- 

Stomach  G.  gastro- 

Liver  G.  hepato- 


SURGICAL  AND  GYNECOLOGICAL  NOMENCLATURE       85 


Gall-bladder 

Bile-duct 

Pancreas 

Intestines 

Duodenum 

Jejunum 

Ileum 

Caecum 

Appendix 

Colon 

Rectum 

Anus 

Urinary  System: 
Urethra 
Bladder 
Ureter 
Kidney 
Pelvis  of  kidney 

Female  Genital  System 
Vulva 
Perineum 
Labium 
Vagina 
Cervix 
Womb 

Fallopian  tube 
Ovary 

Regions  of  Body: 
Head 
Neck 
Chest 
Abdomen 

Tissues : 
Skin 
Fat 

Muscle 
Bone 
Marrow 
Cartilage 


L.  duodeno- 
L.  jejuno- 
L.  ileo- 
L.  caeco- 
L.  appendico- 

L.  recto- 
L.  ano- 


L.  reni  or  reno- 


L.  vulvo- 

L.  labio- 
L.  vagino- 
L.  cervico- 
L.  utero- 

L.  tubo- 
L.  ovario- 


L.  cervico 
L.  abdomino- 


L.  musculo- 


G.  cholecysto- 
G.  choledocho" 
G.  pancreato- 
G.  entero- 


G.  typhlo- 
G.  colo- 
G.  procto- 


G.  urethro- 
G.  cysto- 
G.  uretero- 
G.  nephro- 
G.  pyelo- 


G.  perineo- 

G.  colpo- 
G.  trachelo- 
hystero- 
metro- 
G.  salpingo- 
G.  oophoro- 


G.  cephalo- 
G.  trachelo- 
G.  thoraco- 
G.  celio- 


G.  dermato- 
G.  lipo- 
G.  myo- 
G.  osteo- 
G.  myelo- 
G.  chondro- 


In  the  preceding  list,  the  actual  word  has  not  been  given, 
but  the  root  form  (as  found  under  altered  conditions  in  our 
compound  words)  is  presented.  Such  a  list  is,  necessarily,  full 
of  omissions,  but  should  (taken  in  connection  with  those  follow- 
ing) give  a  fairly  comprehensive  working  idea  of  those  names 
used  in  the  diagnoses  of  surgical  diseases  and  the  operations  for 
their  relief. 


86  THE  FIELD  OF  SURGERY 

Prefixes. — As  has  already  been  stated,  the  prefix  usually 
describes  some  variation  from  the  normal  or  defines  the  relation 
of  the  root- word  to  its  environment,  or  of  another  object  to  the 
root-word.  The  succeeding  list  gives  some  of  the  prefixes  in 
most  common  use — and,  at  the  end  of  the  suffixes,  will  be  found 
some  examples  of  the  utilization  of  prefixes,  root-words  and 
suffixes  in  the  formation  of  compound  words.  It  will  be  noticed 
that  these  prefixes  are  taken  from  both  Greek  and  Latin. 

A-  or  An- means  without  or  n»t. 

Ab- means  from. 

Ad- means  to. 

Ante- means  before. 

Anti- means  against. 

Circum- means  around. 

Con- means  together. 

Contra- means  against. 

De- means  down  or  from  or  away. 

Dia- means  through. 

Dis- means  apart. 

Dys- means  difficult  or  painful. 

E- means  without. 

EC- means  out. 

Ecto- means  without  or  on  the  outside  of. 

En- means  in. 

Endo- means  within. 

Epi- means  upon. 

Eu- means  well. 

Ex- means  out  or  away  from. 

Exo- means  outside. 

Extra- means  outside  of  or  beyond. 

Hyper- means  above  or  beyond. 

Hypo- means  deficiency  of  or  under. 

In- means  m,  into  or  not. 

Inter- means  between. 

Infra- means  beneath. 

Intra- means  within. 

Para- means  beside. 

Peri- means  around. 

Poly- means  many. 

Post- means  after  or  behind. 

Pre- means  before. 

Re- means  again. 

Retro- means  backward. 

Sub- means  below  or  under. 

Super- means  above. 

Supra- means  above. 

In  the  list  above,  there  are  necessarily  a  number  of  prefixes 
which  are  less  common  than  the  others.  In  the  succeeding  list 
of  suffixes,  however,  it  is  fairly  safe  to  say  that  the  very  large 
majority  (if  not  all)  will  be  constantly  encountered  in  terms 


SURGICAL  AND  GYNAECOLOGICAL  NOMENCLATURE      87 

used  in  the  wards  and  in  the  operating-room,  particularly  the 
latter.  Many  medical  and  the  greater  part  of  surgical  diagnoses 
and  nearly  all  surgical  operations,  when  described  in  medical 
terms,  will  include  one  or  another  of  these  suffixes. 

Suffixes: 

-algia means  pain  in. 

-cele means  hernia  of. 

-cleisis means  closure  of. 

-dynia .means  pain  in. 

-ectasis means  dilatation  of. 

-ectomy means  excision  of. 

-ectopy means  displacement  of. 

-itis means  inflammation  of. 

-lith means  stone. 

-oma means  tumor. 

-osis means  disease. 

-pathy means  disease. 

-pexy means  fixation  of. 

-ptosis means  falling  of. 

-rrhaphy means  sewing  of. 

-rrhagia means  bursting  out  from. 

-rrhea means  flowing. 

-rrhexis means  rupture  of. 

-scopy means  viewing  of. 

-stomy means  making  a  mouth  in  or  between. 

-spasm means  spasm  of. 

-tomy means  cutting  of. 

-trismus means  spasm  of. 

Having  attempted  to  give  sufficiently  full  lists  of  root-words, 
prefixes  and  suffixes  to  at  least  give  the  nurse  a  fair  groundwork 
in  building  up  a  surgical  vocabulary — a  number  of  examples  of 
these  built-up  words  will  be  taken  and  separated  into  their 
component  parts,  to  give  an  idea  of  the  application  of  this  sort 
of  learning  in  practical  work. 

First,  let  us  take  that  best  known  of  all  surgical  complaints — 
appendicitis.  We  have  here  a  combination  of  the  root-word 
"appendico"  and  the  suffix  "-itis."  Reference  to  the  lists  will  show 
that  this  combination  means  "inflammation  of  the  appendix." 

As  a  second  example,  let  us  take  another  of  the  more  common 
of  the  disease  conditions  (this  time  gynaecological),  "  endo- 
metritis."  Here  we  find  prefix,  root- word,  and  suffix.  Reference 
to  the  lists  gives  us  the  meanings:  "  endo-,"  within;  "  metro-" 
the  womb;  "-itis,"  inflammation  of.  Hence,  we  have  "  endo- 
metritis,"  or  an  inflammation  of  the  lining  of  the  womb. 

Similarly,  we  have  those  compound  words  that  represent 
operative  procedures,  Gastrostomy  means  making  a  mouth  (or 


88  THE  FIELD  OF  SURGERY 

opening)  in  the  stomach.    Perineorrhaphy  means  sewing  of  the 
perineum.     Cystoscopy  means  viewing  of  the  bladder. 

Abbreviations. — A  discussion  of  the  subject  of  medical  and 
surgical  nomenclature  should  not  entirely  omit  brief  reference 
to  those  abbreviations  commonly  used  in  hospital  work  and  pri- 
vate practice,  when  writing  orders  for  the  nurse's  direction. 
Accordingly,  a  short  list  of  the  more  common  of  these  abbrevia- 
tions, with  their  meanings,  is  appended. 

aa from  ana,  meaning  of  each. 

A.e from  ante  cibum,  meaning  before  meals. 

Ad  lib from  ad  libitum,  meaning  as  desired. 

Aq from  aqua,  meaning  water. 

B.i.d from  bis  in  die,  meaning  twice  daily. 

c from  cum,  meaning  with. 

c.c.  or  c.cm from  cubic  centimetre,  a  unit  of  volume. 

cm from  centimetre,  a  linear  unit. 

G.  or  Gm from  gramme  or  gram,  a  unit  of  weight. 

gtt from  gutta,  meaning  a  drop. 

H from  hora,  meaning  hour. 

P.c from  post  cibum,  meaning  after  meals. 

P.r.n from  pro  re  nata,  meaning  according  to  circumstances. 

Q from  quaque,  meaning  every. 

Q.S from  quantum  sufficit,  meaning  a  sufficient  quantity. 

S.o.s from  si  opus  sit,  meaning  if  necessary. 

68 from  semis,  meaning  half. 

T.i.d from  ter  in  die,  meaning  thrice  daily 


CHAPTER  VI 
THE  SURGICAL  FIELD 

THE  distinction  between  medicine  and  surgery  rests  entirely 
upon  the  methods  of  treatment  employed.  The  word  surgeon 
is  derived  from  two  Greek  words  meaning  hand  and  work.  A 
surgeon,  therefore,  is  one  who  works  with  his  hands,  and  surgery 
is  that  branch  of  the  science  of  medicine  in  which  the  remedial 
measures  that  are  required  consist  of  manual  or  operative  pro- 
cedures. The  diseases  and  affections  with  which  the  surgeon  has 
to  deal  constitute  the  field  of  surgery  and  may  be  briefly  sum- 
marized as  follows: 

I.  OUTLINE  OF  THE  SURGICAL  FIELD 

1.  Affections  Which  Are  not  Caused  by  Disease. — (1)  Ana- 
tomical Defects. — These  may  be  congenital,  as  in  the  case  of 
hare-lip  and  cleft  palate,  or  acquired  after  birth,  as  in  the  case  of 
certain  forms  of  hernia,  and  the  results  of  burns  or  other  injuries. 
The  operative  means  employed  in  their  treatment  are  spoken 
of  as  plastic  or  reparative  operations. 

(2)  Mechanical    Derangements. — Conspicuous    examples    of 
these  are  the  forms  of  intestinal  obstruction  produced  by  torsion 
(volvulus)    or   telescoping    (intussusception)    of    the    intestinal 
tube,  conditions  which  become  rapidly  fatal  if  not  given  prompt 
relief.      Displacement    of   various    abdominal    organs    (floating 
kidney,   enteroptosis)    gives   rise   to   many   distressing   chronic 
symptoms.     Mechanical  distention  of  veins  occurs  in  various 
parts  of  the  body  (varicocele,  varicose  veins  of  the  leg).    Affec- 
tions which  mechanically  interfere  with  the  various  functions 
of  the  body  may  be  the  result  of  injury  and  also  sometimes  of 
disease. 

(3)  Foreign  Bodies. — Various  articles  held  in  the  mouth  and 
accidentally  swallowed  may  become  lodged  in  the  oesophagus, 
stomach,  or  air-passages.     Foreign  bodies,  such  as  bullets  em- 
bedded in  the  tissues,  frequently  require  removal. 

(4)  Trauma. — This  means  any  injury  of  the  tissues  of  the 
body  produced  by  violence.    In  this  class  are  included  wounds, 
open  or  subcutaneous,  contusions  and  crushing  injuries,  burns, 

89 


90  THE  FIELD  OF  SURGERY 

fractures  of  bones,  dislocations  of  joints,  and  any  "  internal  " 
injuries  resulting  from  violent  means.  Surgical  treatment  is 
called  for  in  cases  suffering  from  trauma  always  at  the  time  of 
injury  and  sometimes  later,  after  the  injury  has  healed.  Thus 
accidental  wounds,  like  surgical  wounds,  must  be  properly 
"  closed/'  so  as  to  bring  divided  nerves,  muscles,  skin,  and  other 
tissues  into  normal  position  with  relation  to  each  other;  fractures 
must  be  "  set  "and  retained  in  place  by  splints  or  other  means; 
dislocations  must  be  "reduced";  bleeding  from  divided  arteries 
or  veins  must  be  controlled;  appropriate  steps  must  be  taken  to 
prevent  infection  of  the  injured  tissues;  and  special  methods  of 
treatment  appropriate  to  certain  injuries  too  numerous  to  be 
mentioned  here  must  be  employed.  After  an  injury  has  healed, 
structural  defects  or  other  conditions  resulting  from  it  may 
bring  the  patient  under  the  hands  of  the  surgeon  for  operative 
treatment.  In  the  field  of  gynaecology  the  conditions  resulting 
from  trauma  are  for  the  most  part  those  which  are  incident  to 
child-birth,  such  as  lacerations  of  the  cervix  and  perineum, 
vesicovaginal  fistula,  and  so  on.  These  conditions  frequently 
call  for  operative  repair  at  a  later  period.  The  emergency  meas- 
ures which  the  nurse  may  be  called  upon  to  employ  in  the  immedi- 
ate treatment  of  injuries  will  be  considered  in  a  separate  chapter. 
2.  Diseases  and  Affections  Arising  from  Disease. —  (1)  The 
Infections. — The  greater  number  of  diseased  conditions  caused 
by  the  entrance  of  single-celled  organisms  into  the  body  come 
under  the  care  of  the  physician.  The  principal  organisms  con- 
cerned in  what  may  be  called  the  surgical  infections  have  already 
been  described.  The  bacteria  of  sepsis,  which  have  been  enumer- 
ated in  speaking  of  the  infection  of  wounds,  are  often  encountered 
as  disease-producing  invaders  in  the  body  when  no  visible  wound 
is  present,  having  found  a  portal  of  entrance  through  some  minute 
break  in  the  surface  either  of  the  skin  or  of  the  mucous  mem- 
brane. When  septic  bacteria  are  growing  in  a  number  of  small 
areas  scattered  throughout  the  body,  or  when  the  locality  of 
their  attack  cannot  be  determined,  surgical  treatment  is  not 
available  and  the  disease  must  be  considered  as  belonging  to  the 
province  of  the  physician.  Cases  of  septic  infection  become 
surgical  when  the  disease  is  localized  in  some  definite  area  in 
the  body,  since  in  that  case  the  proper  treatment  consists  in  the 
establishment  of  drainage;  that  is,  the  opening  up  by  operative 
means  of  a  way  of  escape  from  the  body  for  the  poisonous  products 


THE  SURGICAL  FIELD  91 

produced  by  the  growing  bacteria.  In  many  cases  also  portions 
of  tissue  or  even  entire  organs  too  extensively  diseased  to  be 
capable  of  recovery  have  to  be  removed.  Septic  infections  of  this 
character  are  very  common  and  of  great  variety.  They  include 
superficial  lesions,  such  as  boils,  and  carbuncles,  and  ulcers, 
abscesses  in  almost  every  part  of  the  body,  infections  of  the 
serous  membranes  lining  the  great  body  cavities,  such  as  the 
pleura  and  peritoneum.  The  joints  and  even  the  solid  bones  may 
be  the  seats  of  septic  infection.  The  organism  of  Neisser  (gono- 
coccus)  plays  the  leading  role  in  the  pelvic  infections  in  women 
which  are  responsible  for  a  large  proportion  of  the  operative  work 
that  the  gynaecologist  is  called  upon  to  perform.  Infective  lesions 
beginning  in  the  mucous  membrane  of  the  intestine,  and  resulting 
in  perforation  of  the  intestinal  wall,  allow  the  escape  of  highly 
infective  material  into  the  peritoneal  cavity,  and  give  rise  to 
general  or  localized  peritonitis,  requiring  prompt  operative  inter- 
ference for  its  relief.  The  vermiform  appendix  is  by  far  the  most 
common  seat  of  such  perforative  lesions.  The  infection  here  is 
necessarily  of  a  mixed  character,  owing  to  the  varied  bacterial 
content  of  the  material  poured  out  from  the  intestine.  The  colon 
bacillus,  the  staphylococcus,  and  the  streptococcus  are  the  organ- 
isms almost  invariably  found. 

The  tubercle  bacillus  is  the  cause  of  a  great  variety  of  condi- 
tions requiring  surgical  treatment.  This  organism  attacks  almost 
every  tissue  and  organ  in  the  body.  Tuberculosis  of  the  lymphatic 
glands,  of  the  bones  and  joints,  and  of  the  kidney  and  bladder 
are  the  most  common  forms  of  this  disease  which  come  under 
the  care  of  the  surgeon. 

(2)  New-growths. — Nearly  every  tissue    in  the    body   may 
become  the  seat  of  an  abnormal  enlargement  known  as  a  tumor, 
consisting  of  an  excessive  growth  of  tissue  more  or  less  resembling 
the  normal,  usually  with  well-defined  boundaries,  but  tending  to 
progressive  increase  in  size  and  sometimes  to  the  formation  of 
similar  tumors  in  other  parts  of  the  body  at  a  distance,  through 
the  proliferation  of  cells  carried  from  the  original  tumor  through 
the  blood  or  the  lymphatic  circulation.    Very  little  is  known  about 
the  causation  of  these  new-growths.    The  only  successful  treat- 
ment of  them  consists  in  their  removal  by  operative  means. 

(3)  Other  organic  diseases  and  affections  arising  from  them  are 
amenable  to  surgical  treatment  in  numerous  instances  too  varied 
to  be  briefly  summarized.    A  few  examples  must  suffice.    The 


92  THE  FIELD  OF  SURGERY 

harmful  effects  of  an  overactive  or  perverted  gland  secretion 
may  call  for  the  partial  removal  of  the  offending  organ,  as  in  the 
case  of  exophthalmic  goitre.  Obliteration  of  smaller  arteries 
from  chronic  disease  (arteriosclerosis,  diabetes)  may  lead  to 
gangrene  of  the  extremities,  requiring  amputation.  Evacuation 
of  fluid  accumulated  in  various  body  cavities  as  a  result  of  disease 
is  a  surgical  measure  often  called  for.  Concretions  and  calculi 
are  formed  by  the  deposit  of  calcareous  salts  in  various  ducts 
and  passages  of  the  body.  Gall-stones  and  stones  in  the  bladder, 
ureter  or  kidney  are  the  most  common  examples  of  this  class. 
Such  bodies  frequently  require  operative  removal. 

(4)  Functional  Diseases. — Examples  of  purely  functional 
disease,  either  medical  or  surgical,  are  very  few.  Neuralgia  is 
the  name  of  a  condition  in  which  there  is  usually  only  a  single 
symptom  present,  namely  pain,  and  often  no  discoverable  organic 
tissue  change.  Surgical  treatment  is  sometimes  resorted  to  when 
other  means  of  relief  have  failed. 

II.  SURGICAL  SPECIALISM 

The  field  of  surgical  knowledge  is  so  wide  that  it  is  impossible 
for  a  single  mind  to  master  the  innumerable  details  necessary 
to  be  known  in  order  to  do  efficient  work  in  the  diagnosis  and 
treatment  of  surgical  conditions  in  all  parts  of  the  body.  The 
result  is  a  division  of  the  surgical  field  into  a  number  of  depart- 
ments or  specialties,  so  that  by  confining  his  attention  exclusively 
to  one  of  these  a  surgeon  may  attain  a  higher  degree  of  efficiency 
in  his  work.  It  is  the  difficulties  of  diagnosis  rather  than  of 
treatment  that  make  specialism  necessary.  A  large  experience, 
that  is,  the  opportunity  to  observe  and  study  many  cases,  and 
a  wide  scientific  knowledge  are  indispensable  in  making  a  correct 
diagnosis  in  many  cases.  Skill  in  the  use  of  the  many  and  often 
highly  complex  instruments  of  diagnosis  that  have  been  devised 
for  use  in  the  various  special  fields  can  be  acquired  only  by 
constant  practice.  Contrary  to  the  popular  idea,  operative 
skill  is  the  least  important  and  most  easily  acquired  part  of  the 
equipment  of  a  competent  surgeon.  The  recognized  surgical 
specialties  we  may  take  to  be  those  which  are  usually  assigned 
to  separate  departments  in  hospital  work. 

1.  Ophthalmology. — Treatment  of  diseases  of  the  eye  is 
largely  surgical.  It  is  a  wide  field  in  itself,  giving  scope  for  the 
highest  ability  and  skill. 


THE  SURGICAL  FIELD  93 

2.  Otology,  or  surgery  of  the  ear,  is  a  narrower  field  frequently 
combined  with  surgery  of  the  throat  and  nose  or  of  the  eye. 

3.  Surgery  of  the  throat  and  nose  (laryngology,  rhinology)  is 
an  important  specialty  in  which  many  practitioners  are  engaged 
on  account  of  the  great  frequency  of  diseases  and  affections  in 
this  region. 

4.  Gynaecology  deals  with  the  diseases  and  affections  of  the 
female  genito-urinary  organs.     It  is  a  separate  department  in 
most  hospital  organizations,  and  is  a  specialty  of  the  greatest 
interest  and  importance  for  the  surgical  nurse. 

5.  Genito=urinary  surgery  is  the  name  applied  to  that  specialty 
which  deals  with   the  diseases  and  affections  of  the  kidney, 
bladder,  and  genital  organs  in  the  male.     The  setting  aside  of 
this  portion  of  the  surgical  field  as  a  special  department  is  made 
particularly  necessary  by  the  high  degree  of  skill  required  in  the 
use  of  a  wonderful  instrument  of  diagnosis,  the  cystoscope,  by 
means  of  which  the  interior  of  the  bladder  can  be  inspected  and 
surgical  conditions  of  the  kidney  directly  demonstrated. 

6.  Orthopaedic  surgery  deals  with  the   treatment  and   the 
prevention  of  deformities,  particularly  in  children,  either  con- 
genital or  acquired,  the  latter  most  commonly  as  the  result  of 
trauma,  tuberculous  disease  of  the  bones  and  joints,  or  infantile 
paralysis.      The   treatment   of   these   conditions,    while   partly 
operative,  consists  largely  in  the  fitting  of  proper  braces  and 
supports,  and  also  in  the  training  of  particular  groups  of  muscles 
by  special  exercises — forms  of  treatment  which  must  be  carried 
out  over  long  periods  of  time  and  which  require  a  high  degree  of 
patience,  knowledge,  and  skill  in  their  application. 

7.  Surgery  of  the  Nervous  System. — The  brain  and  spinal 
cord  are  subject  to  all  the  forms  of  surgical  disease  and  affection 
that  have  been  enumerated,  especially  perhaps  to  trauma  and  to 
affections  resulting  from  pressure  due  to  the  presence  of  tumors 
or  new-growths.    A  few  practitioners,  exceptionally  well  qualified 
by  reason  of  experience  and  ability,  usually  resident  in  large 
centres  of  population,  have  specialized  in  this  department.     It 
is  perhaps  the  most  difficult  of  all  fields,  but  the  cases  are  not 
numerous  enough   to   support  many  specialists,   and  in   areas 
where  these  are  not  available  such  conditions  come  under  the 
care  of  the  general  surgeon. 

8.  General  surgery  includes  all  that  remains  of  the  wide 
domain  of  surgery  outside  of  the  narrower  fields  included  in  the 


94  THE  FIELD  OF  SURGERY 

special  departments.  There  are,  of  course,  many  border-line 
cases.  A  case  may,  because  of  the  nature  of  the  disease  or  affec- 
tion or  of  its  complications,  come  within  the  province  of  more 
than  one  special  department.  In  operations  within  the  abdomen 
the  work  of  the  general  surgeon  and  that  of  the  gynaecologist 
frequently  overlap.  Both  general  surgeons  and  orthopaedists  treat 
fractures  and  infections  involving  bones  and  joints;  and  there  are 
a  number  of  other  classes  of  operations  which  the  general  surgeon 
has  not  yet  wholly  resigned  to  the  special  department  to  which 
a  strict  classification  might  assign  them. 

III.  OPERATIVE  SURGERY 

1.  Nomenclature. — A  major  operation  is  one  that  is  extensive, 
involving  the  deeper  parts  of  the  body.  A  minor  operation  is 
one  that  involves  only  the  skin  or  mucous  membrane  and  the 
superficial  tissues.  An  operation  is  spoken  of  as  capital  when  it 
involves  danger  to  life;  radical  or  complete  when  it  is  intended  to 
cure  a  disease  or  affection;  palliative  when  it  is  done  to  relieve 
some  distressing  symptom  without  expectation  of  cure.  An 
exploratory  operation  is  one  in  which  an  incision  is  made  to 
bring  into  view  some  deeper  part  of  the  body,  most  frequently 
the  abdomen,  for  purposes  of  diagnosis.  A  plastic  operation  is 
one  where  flaps  of  skin  or  mucous  membrane  are  moved  to  a  new 
position  to  cover  a  defect.  Incision  is  a  simple  cut.  Excision  is 
cutting  out,  to  remove  a  tumor  or  portion  of  tissue  or  organ. 
Resection  is  cutting  from  between,  as  the  removal  of  a  joint,  or 
a  portion  of  a  long  bone,  or  of  a  nerve,  or  of  the  intestinal  tube. 
Anastomosis  is  the  establishment  of  a  communication  between 
portions  of  a  hollow  organ.  The  term  is  applied  to  operations 
of  this  character  on  the  stomach  and  intestines  and  on  arteries 
and  veins.  Many  special  operations  are  known  by  the  name  of 
the  surgeon  who  first  performed  them.  The  meanings  of  many 
compound  words,  including  names  of  operations,  have  been  ex- 
plained in  the  chapter  on  nomenclature.  A  two-stage  operation 
is  one  in  which  at  a  certain  point  the  operation  is  stopped,  the 
wound  closed  and  the  patient  sent  back  to  the  ward.  The  opera- 
tion is  then  completed  at  another  time  some  days  later.  There 
may  be  two  reasons  for  doing  this.  One  is  that  completion  of 
the  operation  at  a  single  stage  would  add  materially  to  the  opera- 
tive risk.  The  other  is  that  in  certain  cases  it  is  desirable  for  the 
healing  process  to  have  time  to  make  a  certain  amount  of  progress 


THE  SURGICAL  FIELD  95 

between  the  first  steps  and  the  later  steps  of  the  operation.  This 
intervention  of  the  healing  process  between  two  stages  of  an  opera- 
tion may  be  required,  for  example,  to  close  off  the  pleural  or  the 
peritoneal  cavity  before  opening  an  abscess  or  a  loop  of  intestine 
which  has  been  drawn  out  to  form  an  artificial  anus.  It  may  also 
be  an  advantage  or  a  necessity  in  certain  plastic  operations. 

2.  Operative  Hazards. — Operative  surgery  has  one  distin- 
guishing characteristic,  of  the  greatest  gravity  and  importance, 
which  it  shares  with  no  other  method  employed  in  the  treatment 
of  disease.  It  is  attended  in  many  cases  with  danger  to  the  life 
of  the  patient.  In  the  treatment  of  medical  cases  an  overdose 
of  a  drug  may  kill,  or  an  error  in  treatment  may  hasten  the  inevi- 
table end  or  permit  a  fatal  issue  that  could  have  been  avoided; 
but  almost  without  exception  every  properly  used  therapeutic 
measure,  other  than  surgical,  is  free  from  direct  hazard  to  life 
or  health.  This  feature  of  the  work  of  the  surgeon  has  undergone 
a  great  and  wonderful  change  for  the  better  within  the  last  fifty 
years.  Before  the  days  of  antiseptic  and  aseptic  surgery,  the 
operative  risks  were  appalling.  Operations  that  are  now  done 
daily  with  scarcely  a  thought  of  danger  were  then  attended  with 
a  death  rate  of  thirty  to  fifty  per  cent,  or  more.  Many  opera- 
tions now  regarded  as  very  moderate  risks  could  not  be  under- 
taken at  all.  The  elimination  of  septic  infection  in  surgical 
wounds,  which  began  with  the  work  of  Lister,  has  thus  wrought 
a  truly  revolutionary  change  with  respect  to  operative  hazards, 
and  other  important  advances  have  contributed  largely  to  the 
same  end.  The  time  will  never  come  when  all  surgical  operations 
will  be  free  from  danger,  but  under  modern  conditions,  in  the  hands 
of  competent  surgeons  and  properly  trained  nurses,  we  may 
roughly  group  all  operations  into  three  classes  with  respect  to 
operative  risks:  (1)  the  largest  class  includes  all  minor  and  many 
major  operations,  numbering  possibly  three-fifths  of  all  cases, 
in  which  the  danger  is  negligible,  being  scarcely  more  than  that 
from  the  ordinary  accidents  of  daily  life;  (2)  a  smaller  but  numer- 
ous group  of  cases  in  which  there  is  a  risk  varying  from  very 
moderate  to  moderately  grave;  (3)  a  small  group  of  cases  involv- 
ing very  grave  risk. 

The  three  primary  operative  risks  are  shock,  hemorrhage, 
and  infection,  including  sepsis  and  pneumonia.  All  of  these  are 
preventable  in  most  cases  with  a  very  high  degree  of  certainty. 
There  are  a  number  of  other  operative  dangers  that  are  under 


96  THE  FIELD  OF  SURGERY 

less  perfect  control  and  also  very  much  less  frequent,  and  one 
or  two,  fortunately  rare,  against  which  we  have  as  yet  practically 
no  safeguards.  The  character  of  the  various  dangers  and  the 
methods  of  forestalling  and  combating  them  will  be  considered 
in  a  later  chapter.  As  regards  time,  the  critical  period  following 
an  operation  may  be  said  to  last  from  three  to  five  days,  after 
which,  if  all  has  gone  well,  the  patient  may  usually  be  considered 
out  of  danger. 

3.  Mortality   (as  applied  to  operative  surgery)   means  the 
death  rate  expressed  in  percentage ;  that  is,  the  number  of  deaths 
in  every  hundred  operations  (of  the  particular  kind  in  question) 
that  have  been  recorded.     Mortality  is  usually  estimated  for 
each  particular  operation  without  regard  to  other  factors  which 
influence  it,  since  these  are  very  variable  and  difficult  to  determine 
accurately.    The  direct  causes  of  death  are  numerous,  including 
the  immediate  effect  of  the  operation  itself  and  all  the  complica- 
tions that  may  arise  afterward.    The  predisposing  causes  are  the 
factors  which  chiefly  affect  mortality,  and  these  may  be  grouped 
under  four  heads:    (1)  The  extent  and  severity  of  the  operation. 
For  example,  the  mortality  of  amputations  at  the  hip-joint  is 
much  greater  than  that  of  amputations  at  the  knee.     (2)  The 
character  of  the  operation  without  regard  to  its  severity.     For 
example,  the  mortality  of  ligation  of  the  common  carotid  artery, 
a  comparatively  simple  operation  in  itself,  is  very  high  because 
of  the  shutting  off  of  the  blood  supply  from  the  brain.    (3)  The 
resisting  power  of  the  patient,  a  factor  which  must  always  be 
carefully  estimated  beforehand  by  the  surgeon.     (4)  The  thor- 
oughness and  conscientiousness  with  which  the  details  of  asepsis 
and  other  parts  of  the  technic  are  carried  out. 

4.  Morbidity  (in  relation  to  operative  cases)  means  the  period 
of  illness  following  an  operation.     It  is  ordinarily  measured  by 
its  duration.    There  is  an  unavoidable  morbidity  following  every 
operation.     A  patient  operated  upon,   often  with  unimpaired 
general  health  beforehand,  then  passes  through  what  may  be 
regarded  as  an  acute  illness,  and  for  practical  purposes  this  may 
be  said  to  last  as  long  as  he  is  disabled  from  his  ordinary  occupa- 
tion.    For  uncomplicated  abdominal  operations  the  minimum 
duration  of  morbidity  may  be  set  at  about  two  weeks,  for  slighter 
operations  it  will  be  considerably  less,  and  in  the  severer  cases 
may  extend  to  a  month  or  more.     When  complications  arise 
morbidity  may  be  prolonged  to  an  indefinite  extent.    Morbidity 


THE  SURGICAL  FIELD  97 

is,  of  course,  subject  to  variation  in  severity  or  intensity  as  well 
as  in  duration. 

5.  The  Surgical  Obligation. — The  operative  hazard  imposes 
upon  the  surgeon  and  upon  the  surgical  nurse  a  unique  and  pecu- 
liarly binding  obligation.  In  no  other  occupation  is  a  serious 
risk  of  life  involved  to  the  recipient  of  a  personal  service.  The 
patient,  therefore,  is  compelled  to  repose  a  great  trust  in  those 
into  whose  hands  he  commits  himself,  and  the  possibility  of 
failing  him  in  any  avoidable  way  is  not  a  matter  to  be  lightly 
regarded.  For  a  patient,  in  good  general  health  and  undergoing 
an  operation  of  slight  or  moderately  grave  danger,  to  die  as  a 
direct  result  of  the  operation  is  a  disaster  of  such  magnitude 
that  no  labor  or  painstaking  care  is  too  great  to  be  exacted  of 
those  responsible  for  the  work.  In  the  graver  cases  the  result 
may  turn  on  small  things.  A  failure  to  estimate  properly  some 
factor  in  the  patient's  condition,  a  slip  in  the  technic,  a  failure 
through  carelessness  to  notice  in  time  premonitory  symptoms  of  a 
coming  complication,  delayed  or  perfunctory  carrying  out  of  an 
important  remedial  measure,  may  determine  a  fatal  issue.  In 
the  majority  of  operations  the  risks  are  small,  but  they  are  in- 
creased in  proportion  whenever  any  failure  occurs  in  applying 
all  available  means  for  safeguarding  the  patient.  The  responsi- 
bility for  this  rests  principally  and  primarily  upon  the  surgeon, 
but  the  surgical  nurse  shares  it  with  him  in  large  measure  in 
certain  aspects  of  the  work,  particularly  in  the  operating-room 
technic  and  in  the  care  of  the  patient  after  operation. 


PART  III— MINOR  TECHNIC  IN 
SURGICAL  NURSING 


CHAPTER  VII 
POSTURES 

IN  the  various  procedures  of  surgery  and  gyrisecology ,  whether 
for  purposes  of  examination,  treatment  ocf  operation,  Jbh^pe  r.re 
numerous  variations  of  the  posture  of  the  patient  that  are  re- 
sorted to  for  the  purpose  of  simplifying  the  anticipated  procedure. 
The  greater  part  of  these  postures  are  really  variations  of  the 
horizontal  recumbent  position,  and  will  be  considered  as  such 
in  their  regular  order  as  decided  by  the  degree  of  variation  from 
the  original  position. 

1.  Horizontal  Recumbent  Position  (Fig.  36). — This  position, 
as  the  name  would  imply,  is  that  normally  taken  by  the  patient 
when  reclining  flat  upon  the  back.     The  legs  are  together  and 
the  arms  may  be  in  any  of  three  positions,  depending  upon  the 
object  in  view  and,  partly,  upon  the  preference  of  the  physician. 
For  purposes  of  abdominal  operation  upon  the  lower  abdomen 
or  of  abdominal  examination,  the  arms  may  be  placed  either 
alongside  the  body,  across  the  chest,  or  above  the  head.    If  the 
operation  is  to  be  upon  the  upper  abdomen,  the  position  of  the 
arms  across  the  chest  would,  naturally,  be  undesirable,  as  they 
might  interfere  with  the  operator.     In  this  case,  either  of  the 
other  arrangements  would  be  equally  satisfactory. 

2.  Trendelenburg  Position  (Fig.  37). — This  position  is  identi- 
cal with  the  horizontal  recumbent  so  far  as  the  immediate  relation 
of  the  patient  to  the  top  of  the  table  is  concerned.    The  difference 
in  the  two  positions  is  based  upon  the  changing  of  the  level  of 
the  table  top.    By  a  mechanical  adjustment  upon  the  table,  the 
patient's  head  is  lowered  so  that  the  top  of  the  table  takes  an 
angle  of  anywhere  from  10  degrees  to  45  degrees  with  the  horizon. 
The  object  of  this  position  is  the  gravitation  of  the  intestines 
out  of  the  pelvis  into  the  upper  abdomen.    For  the  proper  use 
of  this  position,  it  is  necessary  to  have  a  table  with  shoulder 
supports  and  a  sectional  arrangement  by  which  the  lower  end 
may  be  depressed  so  that  the  legs  are  flexed  on  the  thighs.    This 
combination  gives  proper  support  to  the  patient  so  as  to  prevent 
slipping  off  the  table  in  the  higher  elevations.    The  position  is 
generally  taken  just  after  the  abdomen  is  opened. 

101 


102  MINOR  TECHNIC  IN  SURGICAL  NURSING 

3.  The  Reversed  Trendelenburg  Position. — As  the  name 
would  signify,  this  position  is  identical  with  the  last  mentioned, 
except  for  the  reversal  of  the  patient's  position.  Here  the  feet, 
instead  of  the  head,  are  lowered.  Its  application  is  not  a  very 


FIG.  36. — Horizontal  recumbent  position. 

wide  one, — resort  being  had  to  it  only  in  those  infectious  cases 
where  it  is  vital  to  take  every  precaution  to  prevent  already 
existent  pus  from  gravitating  into  the  upper  abdomen.  Where 


FIG.  37. — Trendelenburg  position. 


used,  this  position  is  arranged  at  the  very  outset, — the  patient 
being  put  on  the  table  in  this  position.  The  patient  is  generally 
retained  in  position  by  adhesive  plaster  strapping,  by  towels  or 
straps  passed  around  the  thighs  and  fastened  to  the  table,  and  by 


POSTURES 


103 


the  use  of  a  board  supported  on  the  shoulder  rests, — used  in  this 
position  as  a  foot  rest. 

4.  Dorsal  Position  (Fig.  38).— This  position,  above  the  hips, 
is  identical  with  the  horizontal  recumbent  position.  Here,  how- 
ever, the  thighs  are  flexed  upon  the  body  and  the  legs  upon  the 
thighs, — the  heels  resting  in  stirrups  that  are  adjusted  to  arms 
attached  to  the  table.  The  flexion  of  both  thighs  and  legs  is 
moderate,  as  is  the  separation  of  the  thighs.  This  position  is 
particularly  adapted  to  vaginal  inspection,  or  the  digital  and 
bimanual  examination. 


FIG.  38. — Dorsal   position. 

5.  Dorsal  Elevated  Position. — This  position  differs  from  the 
simple  dorsal  position  only  in  the  elevation  of  the  shoulders  of 
the  patient,  by  placing  enough  pillows  or  pads  under  them  to 
attain  the  desired  elevation.  The  advantage  of  this  position 
over  the  former  is  in  those  cases  where  it  is  necessary  to  flex  the 
body  in  order  to  relax  the  abdominal  muscles  for  proper  bimanual 
examination  of  the  pelvic  organs. 

6.  Dorsosacral  (Lithotomy)  Position  (Fig.  39). — The  dorso- 
sacral  (lithotomy)  position  differs  from  the  dorsal  only  in  the 
matter  of  degree  and  the  method  used  in  its  attainment.  Instead 
of  a  slight  flexing  of  the  thighs  upon  the  abdomen  and  legs  upon 
the  thighs,  the  flexion  is  pronounced,  the  angles  formed  between 


104  MINOR  TECHNIC  IN  SURGICAL  NURSING 

the  respective  parts  being  90  degrees  or  less.  Instead  of  the 
simple  stirrup  foot  rest,  an  upright  rod  with  foot  sling  is  attached 
to  each  side  of  the  table  and  the  legs  flexed  sharply  back, — the 
foot  passing  to  the  outer  side  of  the  rod  and  through  the  sling. 


FIG.  39. — Dorsosacral  (lithotomy)  position. 

This  position  is  used  for  perineal  and  vaginal  operations  and  for 
operations  upon  the  rectum.  It  is  also  used  for  the  cystoscopic 
examination  of  the  bladder  with  the  electric  cystoscope. 

7.  Elevated  Dorsosacral  Position. — The  difference  between 
the  simple  and  elevated  dorsosacral  positions  is  diametrically 


POSTURES 


105 


opposite  to  that  between  the  simple  and  elevated  dorsal  positions. 
Here  it  is  the  hips  that  are  elevated  by  pads  or  the  Trendelenburg 
attachment.  The  elevated  position  is  sometimes  preferred  for 
the  sake  of  convenience  and  is  also  used  by  some  physicians  for 
bladder  examination  with  the  Kelly  cystoscope. 

8.  Right  (or  Left)  Lateral=Prone  Position  (Fig.  40).— This 
position  is  also  known  as  the  Sims  position  and  is  practically 
identical  with  the  kidney  position.  As  a  gynaecological  posture, 
it  is  used  for  inspection  of  the  vulva,  vagina  and  cervix,  or  for 
local  treatment  of  the  same  parts. 

In  this  position,  the  patient  is  placed  on  her  side  at  the  edge 
of  the  table, — with  her  lower  arm  behind  her  and  her  upper  arm  in 
front  and  flexed  naturally  across  her  chest.  Both  knees  are  drawn 


FIG.  40. — Right  lateral-prone  position. 

up  toward  the  body, — the  upper  higher  than  the  lower  and  resting 
on  the  table.  The  patient  is  draped  with  a  sheet  so  that  the  body 
and  legs  are  covered  and  only  the  parts  to  be  examined  exposed. 

9.  Knee=chest  (Qenu=pectoral)  Position  (Fig.  41). — This  posi- 
tion is  the  one  of  choice  for  the  examination  of  the  bladder, 
vagina  or  rectum  by  a  tubular  speculum  aided  by  air  disten- 
tion.  It  is  most  commonly  used  in  connection  with  the  Kelly 
cystoscope. 

The  patient  kneels  upon  the  table,  with  her  feet  extending 
over  the  edge.  The  knees  are  slightly  separated.  Her  face  is 
turned  to  one  side  and  rested  upon  a  pillow  provided  for  the 
purpose, — the  upper  chest  resting  upon  the  table  as  near  as  pos- 
sible to  the  knees.  The  points  to  be  chiefly  observed  in  the  proper 
attaining  of  this  position  are:  (1)  the  maintaining  of  a  vertical 


106  MINOR  TECHNIC  IN  SURGICAL  NURSING 

position  of  the  thighs;  and  (2)  the  resting  of  the  chest  upon  the 
table.  The  patient  should  be  draped  so  as  to  expose  the  vulva 
alone. 

10.  Erect  Position. — This  position  is  particularly  adapted  to 
vaginal  examination  for  the  purpose  of  determining  the  presence 
or  degree  of  prolapse  of  the  uterus.  The  patient  may  take  either 
of  two  positions:  (1)  with  the  foot  resting  upon  the  round  of  a 


FIG.  41. — Genu-pectoral  (knee-chest)  position. 

chair  and  the  corresponding  hand  upon  the  chair's  back, — the 
other  hand  resting  upon  her  hip;  or  (2)  with  feet  separated  and 
both  hands  resting  upon  her  hips. 

VARIATIONS  FROM  THE  USUAL  ARRANGEMENT  AND  EQUIP- 
MENT IN  OPERATIONS 

While  the  foregoing  descriptions  may  be  accepted  as  the  rule 
and  followed  in  those  cases  where  circumstances  and  the  equip- 
ment permit,  there  are  necessarily  times  when  the  usual  wealth 
of  supplies  found  in  the  well-regulated  operating  room  will  be 
lacking  and  when  the  best  must  be  done  with  the  materials  at 
hand.  This  is  particularly  the  case  with  operations  in  private 
houses,  where  the  operating  table  may  be  supplied  by  that 
ordinarily  used  in  the  kitchen  and  the  other  necessities  by  the 
surgeon  or  the  household  linen  room.  In  discussing  these  cases, 
but  brief  reference  will  be  made  to  those  supplies  that  may  be 


POSTURES  107 

brought  by  the  surgeon  and  more  full  description  of  those  pro- 
cedures by  which  the  nurse  may  be  required  to  overcome  the 
natural  difficulties  of  the  situation  as  it  bears  upon  that  branch 
of  the  subject  under  discussion. 

1.  The  Trendelenburg  Position. — In  abdominal  gynaecologi- 
cal operations  in  private  houses,  it  is  the  duty  of  the  surgeon  to 
provide  the  necessary  apparatus  for  obtaining  the  Trendelenburg 
position  (Fig.  37),  should  he  desire  to  use  it.    There  are  frames 
specially  designed  for  this  purpose  and  made  by  the  instrument 
makers  in  a  portable  form.    A  rough  substitute  may,  however, 
be  made  by  reversing  a  straight-backed  chair  so  that  it  rests 
upon  the  front  edge  of  the  seat  and  the  top  of  the  back. 

2.  The  Lithotomy  Position. — This  is  a  position  that  is  used 
in  most  of  the  gynaecological  operations  performed  in  private 
houses,  as  it  is  generally  minor  operations  that  are  done  in  these 
surroundings.     Evidently,  the  kitchen  table  has  no  lithotomy 
posts  or  foot  holders,  nor  attachments  for  their  adjustment. 
Assuming  that  the  surgeon  has  not  brought  his  own  table  with 
the  necessary  appliances,  how  is  the  difficulty  to  be  met?     If 
properly  supplied,  the  surgeon  may  meet  the  emergency  by 
bringing  adjustable  lithotomy  posts  and  foot  holders  or  one  of 
the  lithotomy  slings  with  which  the  market  is  deluged.    If  not, 
the  nurse  must  meet  the  requirements  as  best  she  may  with  the 
supplies  at  hand.    The  lack  is  usually  supplied  by  a  large  bed 
sheet,  so  folded  and  applied  as  to  maintain  the  patient  in  the 
desired  position.    There  are  two  methods  in  general  use,  either 
of  which  is  likely  to  give  satisfaction.    In  the  first,  a  large  sheet 
is  folded  diagonally  and  placed  on  the  table  with  the  long,  folded 
edge  under  the  patient's  shoulders  and  the  apex  hanging  over 
the  lower  end  of  the  table.    The  patient  is  then  placed  in  the 
lithotomy  position  and  the  long  ends  of  the  sheet  that  hang  down 
the  sides  of  the  table  are  brought  under  the  thighs,  between  the 
legs  and  up  the  body,  being  tied  under  the  patient's  neck  by 
carrying  one  under  the  neck  and  tying  to  the  other.     A  sheet 
properly  adjusted  in  this  manner  will  hold  the  patient  in  a  very 
satisfactory  lithotomy  position.    The  second  method  consists  in 
folding  a  sheet  in  several  thicknesses  lengthwise  until  it  is  only 
from  eight  to  twelve  inches  wide.    The  sheet  is  then  passed  under 
the  table  and  the  ends  brought  out  up  over  the  body  of  the 
patient.    The  patient  is  put  in  the  lithotomy  position  and  the 
two  ends  of  the  sheet  carried  between  the  thighs,  outward  over 


108  MINOR  TECHNIC  IN.  SURGICAL  NURSING 

them  with  sufficient  force  to  hold  the  thighs  well  flexed  in  posi- 
tion and  fastened  securely  to  the  part  coming  up  over  the  table, — 
several  safety  pins  serving  very  well  for  this  purpose. 

3.  The  Knee=Chest  Position. — The  knee-chest  position  under 
an  anaesthetic.  It  is  quite  true  that  this  position  is  neither 
generally  nor,  indeed,  very  frequently  used  hi  conjunction  with 
general  anaesthesia.  But,  at  the  same  time,  it  is  true  that, 
when  the  occasion  does  arise,  the  confusion  is  all  the  greater 
for  the  very  infrequency  of  its  use.  There  are  two  solutions  of 
the  difficulty,  a  plenitude  of  assistants  to  hold  the  patient  in 
position  or  lithotomy  posts  and  slings.  The  sling,  in  this  case, 
should  be  a  broad  and  well-padded  one,  as  the  weight  of  the 
patient  must  be  sustained  by  resting  her  thighs  in  these.  The 
patient  is  put  in  the  knee-chest  position,  after  being  completely 
under  the  influence  of  the  anaesthetic,  and  the  slings  placed  around 
her  thighs  and  fastened  to  the  posts,  in  such  a  manner  as  to 
support  her  weight  and  maintain  her  in  the  proper  position. 


CHAPTER  VIII 

BANDAGING 
I.  PRINCIPLES  OF  BANDAGING 

IT  is  impossible,  in  a  brief  chapter,  to  describe  in  detail  all 
the  numerous  and  often  complex  ways  of  applying  a  bandage 
that  have  been  devised,  and  it  is  also  unnecessary,  since  the  nurse 
will  rarely  if  ever  be  called  upon  to  apply  any  but  the  more 
simple  forms.  As  a  matter  of  fact,  the  surgeon  rarely  adheres 
strictly  to  the  rules  laid  down,  but  varies  his  methods  to  suit 
the  individual  case.  There  are,  however,  certain  fundamental 
principles  in  bandaging  that  are  of  the  greatest  importance,  and 
these  should  be  as  clearly  understood  by  the  nurse  as  by  the 
surgeon.  A  badly  applied  bandage  may  be  a  source  of  great 
discomfort  and  even  of  serious  danger  to  the  patient.  A  bandage, 
although  properly  applied  at  the  time  it  was  put  on,  may  later 
become  ineffective,  or  possibly  injurious,  because  of  a  change  in 
the  condition  of  the  part  bandaged,  for  example,  through  in- 
creased or  diminished  swelling,  or  because  of  a  change  in  the 
position  of  the  part,  or  a  disarrangement  of  the  bandage  itself, 
due  to  accident  or  other  cause.  When  such  a  condition  arises 
the  nurse  will  usually  have  the  first  opportunity  to  recognize 
the  fact,  and  she  should  be  able  to  understand  what  is  wrong 
so  as  to  call  the  attention  of  the  surgeon  to  it,  either  immediately 
or  at  his  next  visit,  according  to  the  circumstances  of  the  case. 
When  a  surgeon  has  occasion  to  examine  a  bandage  that  has 
been  applied  by  an  inexperienced  student,  interne  or  nurse,  he 
will  not  observe  or  criticise  the  character  of  the  "  turns  "  selected 
(spiral,  reverse  or  figure-of-eight),  or  whether  these  are  put  on 
in  the  exact  order  or  manner  described  and  pictured  in  the  text- 
books. What  he  will  note  particularly,  on  the  other  hand,  will 
be  the  character,  amount  and  distribution  of  the  dressing  or 
padding  material  under  the  bandage;  the  area  included,  whether 
too  scanty  or  too  extensive;  whether  the  bandage  is  applied  so 
as  to  have  the  proper  grasp  of  the  limb  or  other  part  of  the  body 
to  which  it  is  applied,  so  that  it  will  not  tend  to  slip ;  the  amount 
of  tension,  particularly  at  the  edges  and  over  bony  points;  and 
finally  (and  also  of  least  importance),  the  smoothness  and  neat- 
ness of  the  overlying  folds.  A  bandage  that  is  the  perfection 
of  neatness  may  be  hopelessly  bad  in  the  essential  particulars, 

109 


110  MINOR  TECHNIC  IN  SURGICAL  NURSING 

and  some  of  the  most  skilful  surgeons,  although  the  bandages 
which  they  apply  are  models  of  efficiency,  pay  little  or  no  atten- 
tion to  their  external  appearance.  We  may  now  give  a  brief 
summary  of  the  general  principles  of  bandaging  and  these  will 
be  included  under  two  headings,  first  those  which  refer  to  the 
efficiency  of  the  bandage,  its  proper  application  with  reference 
to  the  purpose  for  which  it  is  employed.  These  are  of  the  first 
importance  and  should  always  be  kept  uppermost  in  mind.  Under 
the  second  head  will  be  given  those  points,  of  minor  importance 
relatively,  which  refer  to  the  neat  appearance  of  the  bandage. 
Principles  which  concern  the  efficiency  of  a  bandage: 

1.  An  arm  or  leg,  when  a  bandage  includes  one  or  more  of 
its  joints,  should  always  be  bandaged  in  the  position  it  is  to  remain 
in  afterwards. 

2.  With  a  few  exceptions  a  bandage  should  never  be  applied 
next  the  skin,  an  elastic  padding  usually  of  cotton  being  placed 
between  the  skin  and  the  bandage.    The  exceptions  are  (a)  when 
a  bandage  of  flannel  or  elastic  fabric  is  applied  for  pressure,  (6) 
the  Unna's  paste  bandage,  (c)  the  bandage  for  a  Buck's  extension; 
here  the  padding  is  placed  only  over  bony  points  and  edges. 

3.  Skin  surfaces  should  never  lie  in  contact.    At  the  fold  of 
the  groin,  at  the  bend  of  the  elbow  and  knee,  between  the  fingers 
or  between  the  arm  and  the  side,  padding  should  be  placed  to 
keep  skin  surfaces  apart. 

4.  A  bandage  should  exert  even  pressure  everywhere.    There 
should  be  no  tight  bands. 

5.  When  a  bandage  of  an  arm  or  leg  is  required  to  be  put  on 
with  firm  pressure  for  any  reason  it  should  extend  from  the  base 
of  the  fingers  or  toes  up,  otherwise  constriction  of  the  limb  will 
result  in  swelling  below  the  bandage. 

6.  To  secure  a  proper  grasp  of  the  limb  a  bandage  on  an  arm 
or  leg  should  cover  all  the  space  between  two  joints  or  include 
the  joint  above  or  below  in  the  turns  of  the  bandage. 

Points  which  concern  the  neat  appearance  of  the  bandage : 

1.  The  turns  of  a  bandage  should  lie  flat,  not  with  one  edge 
tight  and  the  other  wrinkled. 

2.  Each  turn  should  overlie  two-thirds  of  the  preceding  turn. 

3.  The  edges  should  lie  in  parallel  lines. 

4.  The  points  where  the  edges  cross  should  lie  in  a  straight 
line. 

These  points  are  well  illustrated  in  Figs.  61  and  62. 


BANDAGING 
II.  FORMS  AND  USES  OF  BANDAGES 


111 


When  we  speak  of  bandages  we  ordinarily  mean  the  roller 
bandage  which  is  so  extensively  used  in  surgery;  but  there  are 
a  number  of  other  forms  which  are  in  constant  use,  some  of 
which  will  be  described  later  in  the  chapter  on  the  operating- 
room  outfit.  Thus  we  have  the  triangular  bandage  (Fig.  42), 
used  as  a  sling  for  the  arm  and  sometimes  for  other  purposes; 
the  T-bandage  (Fig.  43);  the  four-tailed  bandage  (Fig.  44);  the 


FIG.  42. — Triangular  bandage.     (Eliason's  Practical  Bandaging.) 


Fio.  43. — Single  T-bandage. 


FIG.  44.— Four-tailed  bandage. 


plain  abdominal  binder;  the  many-tailed  bandage;  the  Scultetus 
(Fig.  45) ;  and  some  special  forms  of  bandages,  such,  for  example, 
as  those  used  for  supporting  the  female  breast. 

In  the  employment  of  all  these  forms  of  bandages  there  are 
three  principal  purposes  that  are  aimed  at,  either  singly  or  in 
combination.  These  are  (1)  the  retention  of  dressing  materials 
over  a  wound,  (2)  fixation  of  the  part  with  the  aid  of  splints  or 
of  some  stiffening  material  impregnating  the  bandage  itself, 
(3)  the  application  of  pressure. 


112 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


III.  MATERIALS  AND  PREPARATION 

The  materials  of  which  roller  bandages  are  made  are  gauze, 
usually  of  much  finer  mesh  than  the  gauze  used  for  surgical 
dressings,  unbleached  muslin,  crinoline,  flannel,  and  sheet  rubber. 
Each  material  has  its  own  special  use  according  to  the  object 
to  be  attained. 

The  gauze  bandage  is  now  almost  universally  used  for  the 
retention  of  surgical  dressings.  These  bandages  are  furnished 
ready  made  in  all  sizes  by  the  manufacturers,  and  are  for  sale 
at  all  drug  stores,  often  at  rather  fancy  prices.  When  purchased  in 


Fia.  45. — Modified  bandage  of  Scultetus. 

quantity,  however,  they  are  cheap  enough,  so  that  most  hospitals 
no  longer  find  it  an  economy  to  make  their  own  gauze  bandages. 
The  most  common  sizes  are  %  inch  (for  the  fingers),  2^  inches, 
4  inches,  and  6  inches  in  width,  and  from  2  to  10  yards  long. 

The  muslin  bandage,  formerly  the  most  common  form,  is 
now  generally  restricted  in  its  use  to  cases  where  it  is  desirable 
to  exert  a  considerable  amount  of  pressure  on  the  part  to  which 
it  is  applied,  and  to  the  retention  of  splints  and  the  treatment 
of  fractures.  Only  two  sizes  are  ordinarily  used,  2  inches  and 
4  inches  in  width  and  5  yards  long. 

Crinoline  bandages,  because  of  the  starch  with  which  the 
material  is  impregnated,  are  used  to  make  a  stiff  covering  over 
the  gauze  bandages  put  on  to  retain  a  surgical  dressing,  the. 


BANDAGING  113 

object  being  to  make  the  bandage  more  secure  and  give  it  a 
certain  amount  of  rigidity.  Two-and-one-half  and  four-inch 
widths  are  the  usual  sizes.  The  bandages  are  soaked  in  water 
and  wrung  out  before  being  applied.  It  will  add  much  to  the 
surgeon's  good  temper  if  the  nurse  will  remember  to  pull  off  all 
the  ravellings  from  the  edges  of  the  wet  crinoline  bandages  before 
handing  them  to  him.  Crinoline  is  also  used  as  the  material  from 
which  plaster-of-Paris  bandages  are  made. 

Flannel  bandages  are  used  solely  to  exert  pressure,  being 
particularly  adapted  for  this  purpose  on  account  of  their  elas- 
ticity. This  bandage  is  applied  next  to  the  skin  without  any 
intervening  padding.  Four  inches  is  the  usual  width. 


Fia.  46. — Rolling  bandage  by  hand. 

The  bandage  made  of  sheet  rubber,  known  as  the  Esmarch 
or  Martin  bandage,  is  used  at  the  time  of  operation  to  expel 
blood  from  a  limb  and  to  compress  the  vessels  so  as  to  prevent 
hemorrhage.  They  are  made  three  inches  wide. 

Triangular  bandages,  binders,  slings  and  tailed  bandages  are 
made  of  unbleached  muslin  or  of  Canton  flannel.  The  triangular 
bandage  is  made  from  a  thirty-inch  square  of  muslin  folded  or 
cut  diagonally.  Its  principal  use  is  as  a  sling  for  the  arm.  The 
four-tailed  bandage  is  either  a  square  of  muslin,  of  suitable  size 
for  the  purpose  intended,  with  tapes  at  the  corners,  or  is  made 
from  a  strip  of  muslin  bandage,  split  from  each  end  with  the 
scissors,  leaving  an  uncut  portion  in  the  middle.  Their  principal 
use  is  for  dressings  applied  to  the  chin,  the  eye  or  the  ear.  The 
8 


114  MINOR  TECHNIC  IN  SURGICAL  NURSING 

forms   and   sizes   of   plain   and   many-tailed   binders     will    be 
described  in  a  later  chapter. 

In  making  roller  bandages  muslin  may  be  torn  into  strips  of  the 
desired  width,  but  gauze,  crinoline  and  flannel  must  be  cut  with  the 
scissors.  Gauze  and  crinoline  are  cut  in  line  with  the  threads  in  the 
length  of  the  goods.  Flannel  bandages  are  cut  diagonally  across 
the  goods,  the  short  pieces  being  then  stitched  together  to  make 
the  requisite  length.  The  object  of  this  is  to  make  them  elastic. 


FIG.  47. — Bandage  roller. 

Bandages  may  be  rolled  by  hand  (Fig.  46)  or  by  means  of 
one  of  the  simple  machines  provided  for  the  purpose  (Fig.  47). 
Muslin  and  gauze  bandages  should  be  rolled  as  tightly  as  pos- 
sible. Crinoline  and  flannel  bandages  should  be  loosely  rolled. 
All  loose  threads  and  ravellings  should  be  carefully  removed. 

IV.  APPLICATION  OF  THE  ROLLER  BANDAGE.     BANDAGING 
FOR  THE  RETENTION  OF  DRESSINGS 

The  first  consideration  in  bandaging  for  the  retention  of  a 
surgical  dressing  is  the  character  and  distribution  of  the  dressing 
material.  From  every  fresh  clean  wound  there  will  be  for  some 


BANDAGING  115 

hours  an  abundant  discharge  of  watery  fluid  which  oozes  from 
the  divided  capillaries  and  is  derived  from  the  serum  of  the  blood. 
In  infected  wounds  there  is  a  free  discharge  of  pus  or  other  form 
of  inflammatory  exudate.  The  dressing  material  must  be  of 
such  a  character  as  readily  to  absorb  these  fluid  discharges  and 
at  the  same  time  exert  an  elastic,  non-rigid  pressure  in  the 
neighborhood  of  the  wound.  To  meet  these  indications  there 
is  nothing  equal  to  the  absorbent  surgical  gauze  manufactured 
expressly  for  the  purpose.  The  gauze  is  cut  and  prepared  in 
various  forms  and  sterilized  in  packages  wrapped  in  muslin,  or  in 
metal  drums  (see  page  275,  Fig.  88) ,  and  must  be  handled,  of  course, 
only  with  sterile  gloves  or  instruments.  The  manner  of  applying 
the  gauze  dressings  varies  according  to  the  amount  of  discharge 
from  the  wound.  For  the  primary  dressing  of  all  operative  and 
accidental  wounds,  and  for  all  dressings  of  suppurating  wounds 
the  gauze  used  should  not  be  in  the  form  of  pads,  like  a  folded 
handkerchief,  but  in  the  form  of  fluffs,  like  a  handkerchief  shaken 
out  and  lightly  crushed  in  the  hand.  The  dressings  should 
cover  a  rather  wide  area  on  all  sides  of  the  wound,  six  to  eight 
inches  at  least,  except,  of  course,  in  the  case  of  very  small  wounds. 
The  fluffs  should  be  piled  up  to  a  thickness  of  from  two  to  four 
inches  or  even  more  in  the  case  of  large  wounds,  and  should  be 
massed  rather  more  heavily  about  the  circumference  of  the* 
wound  and  rather  more  lightly  directly  over  the  wound  itself. 
When  the  wound  is  on  an  arm  or  leg  a  part  of  the  gauze  dressing 
should  encircle  the  entire  limb,  which  is  best  done  by  means  of 
fluffs  applied  to  the  wound  and  over  them  a  gauze  roll  wound 
about  the  limb.  This  applies  also  to  dressing  wounds  of  the  neck. 
Wherever  skin  contact  occurs,  as'  in  binding  an  arm  to  the  side, 
abundant  padding  should  be  placed  between  the  skin  surfaces. 
When  the  gauze  dressing  has  been  applied  it  is  well  in  some  cases 
to  secure  it  from  slipping  by  means  of  strips  of  adhesive  plaster 
which  pass  across  the  dressing  and  adhere  to  the  skin  on  either 
side.  Over  all  a  gauze  bandage  of  suitable  width  is  now  applied. 
In  the  case  of  abdominal  wounds  a  binder  takes  the  place  of 
the  bandage.  The  bandage  should  cover  the  entire  dressing  and 
extend  a  short  distance  beyond  it  on  every  side.  It  should  be 
so  applied  as  to  have  the  proper  grasp  of  the  limb  or  other  part, 
in  order  that  it  may  not  slip.  This  point  will  be  referred  to 
again  in  the  discussion  of  regional  bandaging.  A  dressing  bandage 
should  never  be  very  tight,  just  sufficient  tension  being  used  to 


116  MINOR  TECHNIC  IN  SURGICAL  NURSING 

make  it  firm  and  secure.  It  should  be,  as  a  rule,  about  as  tight 
as  a  comfortably  fitting  glove.  Occasionally  very  much  stronger 
pressure  must  be  temporarily  applied,  principally  for  the  purpose 
of  controlling  hemorrhage.  Finally,  the  end  of  the  bandage  is 
twisted  into  a  cord  and  fastened  with  a  safety  pin,  preferably  at 
a  point  directly  over  the  wound  itself,  thus  indicating  its  location. 
A  small  square  of  adhesive  plaster  also  answers  well  for  the 
purpose  of  fixing  the  end  of  the  bandage. 

In  cases  where  a  certain  amount  of  rigidity  is  desirable  a  wet 
crinoline  bandage  is  put  on  over  the  gauze  bandage.  This, 
when  dry,  will  give  a  moderately  stiff  superficial  covering.  For 
additional  support,  in  certain  cases,  strips  of  thin,  pliable  wooden 
splints  may  be  incorporated  in  the  bandage. 

When  the  formation  of  pus  is  very  abundant,  or  where  there 
is  a  discharge  of  faeces,  urine,  or  bile  through  the  wound,  the 
dressings  must  be  changed  very  frequently  and  the  means  of 
holding  them  in  place  should  be  arranged  so  that  the  changes 
can  be  easily  made.  The  use  of  short  strips  of  adhesive  plaster, 
two  inches  wide,  attached  to  the  skin  on  either  side  of  the  wound, 
with  tapes  fastened  to  them  to  tie  across  the  dressings,  will  make 
it  easy  to  remove  the  saturated  gauze  and  replace  it  with  a 
fresh  supply.  A  binder  pinned  over  this  dressing  gives  additional 
security.  In  many  cases  when  wet  dressings  are  applied  to  a 
limb  these  must  be  changed  every  three  hours  or  even  oftener, 
and  the  roller  bandage  is  too  cumbersome  a  means  for  holding 
them  in  place.  The  wet  gauze  should  be  loosely  folded  about  the 
limb,  not  wound  around  it  with  many  turns;  it  should  be  cov- 
ered with  a  piece  of  oiled  silk  and  held  in  place  by  means  of  a 
towel  wrapped  about  the  limb  and  fastened  with  safety  pins  or 
by  three  or  four  turns  of  a  gauze  roller. 

In  the  case  of  aseptic  operative  or  accidental  wounds  there 
will  be  no  discharge  after  the  first  few  hours.  For  the  second 
dressing  of  such  wounds  the  requirements  are,  therefore,  quite 
different  from  those  called  for  at  the  first,  since  no  provision 
need  be  made  for  the  absorption  of  fluid  material.  Flat  gauze 
pads  may  now  be  used,  and  these  need  not  be  so  thickly  piled 
or  so  widely  distributed  as  at  the  primary  dressing. 

V.  BANDAGING  FOR  FIXATION 

In  cases  of  fracture,  of  dislocation,  and  of  disease  involving 
a  joint,  the  injured  or  diseased  part  must  be  kept  at  rest  and  in 
a  fixed  position  for  a  considerable  time.  Fixation  of  a  limb  may 


BANDAGING  117 

be  accomplished  by  means  of  padded  splints  held  in  place  by 
strips  of  adhesive  plaster  and  a  gauze  or  muslin  roller  bandage 
or  by  means  of  bandages  impregnated  with  some  substance  like 
plaster-of-Paris  which  will  form  a  rigid  covering  for  the  injured 
part.  The  nurse  may  be  called  upon  to  apply  some  form  of 
fixation  apparatus  as  a  first-aid  measure,  and  it  is  very  desirable 
that  she  should  understand  the  principles  governing  their  use, 
since  a  fixation  bandage  may  be  capable  of  doing  serious  harm 
when  improperly  applied. 

All  splints  or  other  fixation  appliances  should  be  well  padded, 
especially  over  bony  points.  They  should  be  put  on  tightly 
enough  to  ensure  immobility  but  not  enough  to  produce  con- 
striction. The  position  of  a  limb  should  not  be  changed  after  a 
fixation  bandage  has  been  put  on,  since  this  may  cause  undue 
constriction  at  the  point  where  the  joint  is  flexed.  The  usual 
and  normal  position  of  the  various  joints  in  fixation  is  as  follows: 
ankle,  flexed  at  right  angle;  knee,  straight;  hip,  straight;  wrist, 
straight  or  slightly  flexed;  elbow,  flexed  at  right  angle;  shoulder, 
in  normal  position  at  side.  There  are  some  exceptions  to  these 
rules ;  for  example,  the  elbow  must,  for  one  fracture  particularly, 
be  put  up  in  the  straight  position,  and  in  many  cases  of  fracture 
at  the  elbow-joint  the  best  position  is  with  the  arm  flexed  at  an 
acute  angle;  but  these  points  are  for  the  decision  of  the  surgeon. 
In  fractures  of  the  shaft  of  a  long  bone  the  bone  itself  and  the 
joint  of  either  side  must  be  included  in  the  fixation.  Some 
exceptions  to  this  rule  occur  in  the  case  of  fractures  close  to  a 
joint  and  in  fractures  of  only  one  of  the  two  bones  in  the  forearm 
or  leg.  Fingers  and  toes,  particularly  the  former,  should  always 
be  left  free  in  applying  fixation  to  a  limb,  unless,  of  course, 
these  are  themselves  the  injured  members.  It  is  the  most  inex- 
cusable kind  of  bad  surgery  to  include  the  fingers  in  a  splint  for 
a  broken  arm.  They  will  inevitably  become  stiff  and  their 
restoration  to  their  normal  suppleness  will  be  an  extremely 
difficult  matter.  When  the  hand  or  foot  below  a  fixation  band- 
age becomes  markedly  swollen  or  cold  and  blue,  the  whole 
bandage,  everything  down  to  the  skin,  must  be  at  once  cut 
with  the  scissors,  even,  if  necessary,  without  waiting  for 
orders  from  the  surgeon.  After  doing  this,  however,  the 
fixation  appliance  need  not  be  removed,  a  very  loose  band- 
age being  put  on  over  it  until  the  surgeon  has  an  opportunity 
to  readjust  it. 


118  MINOR  TECHNIC  IN  SURGICAL  NURSING 

VI.  BANDAGING  FOR  PRESSURE 

Bandaging  for  the  application  of  pressure  may  be  required 
to  control  hemorrhage,  or  to  give  support  and  prevent  swelling, 
as  for  example  in  ankle  sprains  and  varicose  veins  of  the  leg.  A 
pressure  bandage  must  always  extend  from  the  toes  or  fingers 
up,  leaving  these  free,  otherwise  swelling  will  occur  below  the 
bandage.  Pressure  must  be  elastic,  not  rigid,  and  therefore 
when  either  gauze  or  muslin  bandages  are  used  for  pressure, 
padding  must  be  applied  between  the  bandage  and  the  skin. 
Hospital  wadding  (sheet  cotton  glazed  on  both  sides)  is  the 
best  material  for  this  purpose.  The  diagonally  cut  flannel 


Fio.  48. — Circular  turns  of  a  bandage.     (Eliason's  Practical  Bandaging.) 

bandage  is  sufficiently  elastic  so  that  it  may  be  used  as  a  pressure 
bandage  without  any  padding  under  it.  The  tension  exerted 
by  the  pressure  bandage  must  never  be  sufficient  to  interfere 
seriously  with  the  circulation  of  the  limb.  Badly  injured  tissues, 
or  those  the  subject  of  long-standing  chronic  disease,  and  the 
tissues  of  the  very  young  or  very  old  bear  pressure  badly. 

VII.  THE  "  TURNS  "  USED  IN  BANDAGING 

In  order  to  make  the  folds  of  the  roller  bandage  lie  smoothly 
and  with  equal  tension  it  is  necessary  to  vary  the  manner  of 
placing  them  in  a  number  of  ways  as  the  bandage  is  wound  in 
successive  layers  about  the  limb  or  other  part.  These  various 


BANDAGING 


119 


turns  are  very  simple  in  char- 
acter, but  it  is  difficult  to  de- 
scribe them  clearly,  and  they 
must  be  learned  from  pictures 
and  by  practical  demonstra- 
tion. They  are  six  in  number 
and  are  known  as  the  "  circu- 
lar," the  "spiral,"  the  "  ob- 
lique," the  "  reverse,"  the 
" figure-of-eight,"  and  the  "re- 
current "  turns.  A  bandage 
may  be  applied  using  one  of 
these  turns  exclusively,  or  two 
or  more  in  combination,  or 
even  changing  from  one  to 
another  at  each  successive 
encircling  of  the  part  with  the 
bandage,  unconsciously  select- 
ing each  time  the  particular 
turn  that  is  best  adapted  to 
the  case  in  hand,  and  forget- 
ting all  the  rules  laid  down  in 
the  text-books  on  the  subject. 
This  latter  method  is  the  usual 
practice  with  those  who  do 
much  bandaging  and  gives  the 
best  results  as  regards  effi- 
ciency, although  not  always 
the  most  finished  appearance. 

The  circular  turn  is  one 
which  simply  encircles  the  part 
overlying  the  preceding  turn. 
It  is  used  principally  to  fix 
the  free  end  of  the  bandage  at 
the  start  (Fig.  48). 

The  spiral  turn  is  what  its 
name  indicates,  each  turn  over- 
lapping the  preceding  turn  with 
parallel  edges  (Fig.  49).  It 

is  applicable  where  the  diam-  no,  49.— Spiral  and  oblique  turns, 
eter  of  the  part  (Joes  not  vary.. 


Practical  Bandaging.) 


(Eliaeon'g 


120 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


In  making  the  oblique  turn  the  bandage  is  allowed  to  fall 
in  any  direction  across  the  limb  where  it  will  lie  smoothly,  no 
attention  being  paid  to  uniform  overlapping  of  the  preceding 
turns. 

The  reverse  turn  (Fig.  50)  is  made  when  it  is  found  that  the 
bandage,  in  order  to  lie  flat,  must  be  made  to  take  a  very  oblique 
direction  across  the  limb  and  the  next  turn  will  carry  it  beyond 
the  area  to  be  included  in  the  bandage.  The  bandage  is  then 
"  reversed,"  that  is,  turned  over,  making  a  diagonal  fold  across 
its  width,  so  that  what  was  the  outer  surface,  away  from  the 


FIG.  50. — Making  reverses. 

skin,  now  becomes  the  inner  surface,  towards  the  skin,  and  the 
course  of  the  bandage  takes  a  new  direction.  This  turn  is  used 
where  there  is  variation  in  the  diameter  of  the  part  to  be  bandaged. 

The  "  figure-of-eight "  (Fig.  51)  really  consists  of  two  turns 
which  cross  each  other  at  an  angle  on  the  front  or  back  of  the 
limb.  A  figure-of-eight  bandage  passing  from  the  thigh  to  the 
trunk  or  from  the  arm  to  the  shoulder  is  called  a  "  spica  " 
bandage  (Fig.  52). 

Recurrent  turns  (Fig.  53)  are  made  by  folding  the  bandage 
back  and  forth  upon  itself,  the  bends  of  the  folds  being  then 
caught  by  a  circular  turn.  It  is  used  in  bandaging  the  head, 


BANDAGING 


121 


Fia.  51. — Figure-of-eight  turns.    (Eliason's  Practical  Bandaging.) 

covering  in  the  ends  of  the  fingers  or  an  amputation  stump 
(Fig.  54),  making  a  suspender  over  the  shoulder  for  a  breast 
bandage,  and  so  on. 


122  MINOR  TECHNIC  IN  SURGICAL  NURSING 

VHI.  REGIONAL  BANDAGING 

1.  The  Head. — Bandages  of  the  head  for  the  retention  of 
dressings  may  include  (1)  only  the  scalp  region,  with  the  fore- 
head; or  (2)  the  scalp  region  and  the  neck;  or  (3)  in  addition 
to  these  the  chin  may  be  included  by  turns  which  pass  from  the 


FIG.  52. — Spica  of  the  hip. 


FIG.  53. — Recurrent  of  the  scalp  (first  step). 
(Eliason'a  Practical  Bandaging.) 


top  of  the  head  in  front  of  the  ear  and  under  the  chin,  thus  cover- 
ing everything  but  the  face.  In  the  first  case  circular  turns  pass 
under  the  occiput  (Fig.  55)  as  low  down  as  the  hair  line  at  the 
back  of  the  neck  and  around  the  forehead,  these  holding  recurrent 
turns  which  pass  over  the  top  of  the  head;  or  the  scalp  may  be 


FIG.  54. — Recurrent  bandage  of  the  stump. 

covered  by  oblique  and  reverse  turns  caught  under  the  circular 
turns.  The  ears  should  be  left  out,  or,  if  included,  padding 
should  be  placed  behind  and  over  each  ear  to  protect  it  from 
pressure.  When  the  neck  is  included,  or  the  neck  and  chin, 
figure-of-eight  turns  are  used  crossing  at  the  back  of  the  neck 


BANDAGING 


123 


FIG.  55. — Recurrent   turns.      (Eliason's 
Practical  Bandaging.) 


FIQ.  5fi. — Figure-of-eight  of  the  head  and  neck 
(Eliason's  Practical  Bandaging.) 


Fio.  57. — Double  oblique  of  the  jaw. 
(Eliason's  Practical  Bandaging.) 


Fia.  58. — Four-tailed  bandage  of  the  chin. 
(Eliason's  Practical  Bandaging.) 


124 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


(Fig.  56)  or  under  the  chin,  or  at  both  these  points  (Fig.  57). 
Fracture  and  dislocation  of  the  lower  jaw  are  the  only  conditions 
calling  for  fixation  bandages  applied  to  the  head.  A  four-tailed 
bandage  over  the  point  of  the  chin  with  the  tails  tied  behind 
the  neck  and  at  the  top  of  the  head  is  the  simplest  appliance 
for  this  condition  (Fig.  58).  When  the  roller  is  used  a  sort  of 
triple  figure-of-eight  with  crossing  points  at  the  chin,  at  the  top 
of  the  head,  and  at  the  occiput  (Barton's  bandage)  (Fig.  59), 
or  one  with  the  crossing  point  at  the  chin,  with  turns  to  the  back 


Fia.  59. — Barton's  bandage. 


Fio.  60. — Gibson  bandage.     (Eliason's  Prac- 
tical Bandaging.) 


of  the  neck,  to  the  top  of  the  head,  and  circular  turns  about 
forehead  and  occiput  (Gibson's  bandage),  give  good  fixation  and 
security  (Fig.  60). 

2.  The  Neck. — Bandages  for  the  retention  of  dressings 
including  the  neck  alone  are  never  used  except  for  very  slight 
and  insignificant  wounds,  for  which  a  few  circular  or  oblique 
turns  are  all  that  is  necessary.  For  wounds  of  any  extent  in  the 
neck  the  bandage  must  include  a  number  of  turns  about  the  head 
sufficient  to  secure  the  upper  border  of  the  neck  bandage.  Wounds 
of  the  lower  part  of  the  neck,  and  particularly  those  of  the  throat 
in  front,  will  also  require  figure-of-eight  turns  passing  down  under 
both  arms.  Abundant  dressings  must  be  used  here  and  the 
bandage  must  never  be  tight.  Fixation  appliances  for  the  neck, 


BANDAGING  125 

required  occasionally  for  disease  or  injury  of  the  spine,  must 
possess  a  firm  grasp  upon  the  whole  trunk,  neck,  chin  and  head. 

3.  The  Thorax. — Extensive  dressings  are  often  needed  here, 
particularly  for  operations  on  the  female  breast.    Circular,  spiral 
or  oblique  turns  about  the  body  with  oblique  turns  from  under 
the  arm  over  the  opposite  shoulder  and  recurrent  over  the  shoulder 
will  be  required.    Wide  gauze  bandages  should  be  used  and  care 
should  be  exercised  that  the  turns  about  the  chest  are  not  too 
tight  and  that  they  do  not  extend  too  high  under  the  arms. 
In  extensive  wounds  (e.g.,  complete  operation  for  cancer  of  the 
breast)  the  whole  arm  on  the  wounded  side  should  be  included  in 
the  bandage  and  fastened  to  the  chest  wall.    Abundance  of  safety 
pins  should  be  used  to  secure  the  folds  of  the  bandage.    Fixation 
for  fracture  of  one  or  more  ribs  is  often  called  for,  and  may  be 
accomplished  by  means  of  a  wide  muslin  roller,  a  tight  binder,  or 
wide  strips  of  adhesive  plaster. 

4.  The  Abdomen. — Dressings  of  wounds  in  this  region  are 
usually  secured  by  adhesive  straps  and  a  binder,  the  roller  bandage 
being  rarely  used,  but  bandages  for  the  groin  or  thigh  always 
include  the  lower  abdomen  to  give  them  the  proper  grasp,  and 
for  wounds  of  the  back  in  the  lumbar  region  a  wide  gauze  roller 
may  be  employed.    Fixation  appliances  covering  this  region  are 
always  for  injury  or  disease  of  the  hip  or  of  the  spine. 

5.  The    Extremities. — In    bandaging   for   the   retention   of 
dressings  as  applied  to  either  the  arm  or  leg,  the  figure-of-eight, 
spiral  and  oblique  turns  are  the  ones  to  be  selected  as  a  rule. 
The  reverse  will  rarely  be  called  for.    Where  simply  the  retention 
of  a  dressing,  without  pressure,  is  required,  the  figure-of-eight 
turn  is  to  be  preferred,  since  it  will  be  found  applicable  to  almost 
all  situations,  gives  great  security  and  at  the  same  time  the  most 
finished  appearance  to  the  bandage.     Circular  and  spiral  turns 
will  be  resorted  to  where  firm  pressure  is  required,  as  for  the 
control  of  hemorrhage,  and  recurrent  turns  in  special  situations, 
as  for  covering  an  amputation  stump  or  the  ends  of  the  fingers. 
An  occasional  oblique  or  even  a  reverse  turn  may  be  called  for, 
and  a  few  circular  turns  to  finish  the  edge  of  the  bandage  or  to 
secure  the  recurrent  turns.    The  use  of  the  reverse  turn  will  be 
mostly  confined  to  the  application  of  fixation  appliances  where 
the  bandage  must  follow  up  a  tapering  limb  (Fig.  61)  covered 
with  an  even  thickness  of  padding,  as,  for  example,  in  bandaging 
over  the  adhesive  straps  in  putting  on  a  Buck's  extension,  and  in 


126 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


Fio.  61. — Spiral  reverse  of  lower  extremity.     (Eliason's  Practical  Bandaging.) 


BANDAGING 


127 


applying  a  plaster-of-Paris  cast  for  fixation  of  a  fracture.  The 
flannel  bandage  is  used  almost  exclusively  on  the  foot  and  leg 
(sometimes  the  wrist  and  arm)  to  give  supporting  pressure  in 
cases  of  sprain  or  other  conditions,  such  as  varicose  veins  of  the 
leg.  It  is  to  be  applied  from  the  toes  up  with  figure-of-eight 
turns  for  the  foot  and  spiral  turns  only  for  the  leg,  since  this 
bandage  stretches  so  readily  that  a  reverse  is  never  needed. 


Fia.  62. — Velpeau  modified  (Dulles).     (Eliason'a  Practical  Bandaging.) 

Retention  bandages  for  the  shoulder,  unless  the  wound  is  an 
insignificant  one,  should  fix  the  arm  to  the  side,  with  plenty  of 
padding  between  the  skin  surfaces.  There  are  two  classical 
forms  of  bandage  for  securing  the  arm  to  the  side,  known  as 
the  "  Velpeau  "  (Fig.  62)  and  the  "  Desault  "  bandages.  In 
the  former  the  whole  arm  is  included,  in  the  latter  only  the 
upper  arm  is  fixed,  the  forearm  being  left  uncovered  and  with 
some  freedom  of  motion.  The  position  of  the  arm  for  the  Velpeau 


128 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


bandage  is  with  the  hand  resting  on  the  front  of  the  opposite 
shoulder.  The  bandage  consists  of  spiral  turns  about  the  body 
including  the  arm  and  forearm,  with  alternate  turns  passing 
over  the  shoulder  on  the  injured  side,  from  behind  forwards, 
and  passing  down  under  the  arm  and  forearm.  Desault's  bandage 
is  applied  with  the  arm  lying  straight  across  the  body  at  the  level 


FIG.  63. — Desault  bandage.     (Eliason's  Practical  Bandaging.) 

of  the  lower  ribs.  The  bandage  consists  of  circular  and  spiral 
turns  about  the  arm  and  body,  with  a  final  roller  applied  as  a 
compound  figure-of-eight,  having  three  points  where  the  folds 
cross  (Fig.  63),  over  the  shoulder  on  the  injured  side,  under 
the  elbow  and  under  the  opposite  axilla.  In  the  classical  de- 
scription a  first  roller  fixes  a  pad  in  the  axilla  on  the  injured  side, 
but  this  step  need  not  usually  be  considered  by  the  nurse  in 


BANDAGING 


129 


cases  where  she  may  be  called  upon  to  apply  the  bandage.  It 
must  always  be  remembered,  however,  that  plenty  of  padding 
is  to  be  used  to  prevent  contact  of  skin  surfaces.  Particular  care 
must  be  exercised  to  avoid  pressure  over  the  point  of  the  elbow. 


FIG.  64. — Finger  bandage. 


Fia.  65. — Spica  of  the  foot.     (Eliason's  Practical  Bandaging.) 

The  fingers  are  bandaged  singly  or  two  or  more  together,  a 
three-quarter  inch  gauze  roller  being  used  with  figure-of-eight 
and  recurrent  turns  (Fig.  64).    For  the  foot  and  ankle  a  simple 
application  of  the  figure-of-eight  is  most  suitable  (Fig.  65). 
9 


130  MINOR  TECHNIC  IN  SURGICAL  NURSING 

In  applying  retention  bandages  to  any  part  of  the  arm  or  leg, 
an  ample  area  beyond  the  seat  of  injury  should  be  covered  and 
the  bandage  should  be  so  adjusted  as  to  have  a  proper  grasp 
upon  the  limb  so  that  it  will  not  slip.  To  this  end  the  bandage 
should  always  extend  to  or  over  one  of  the  adjacent  joints.  A 
bandage  of  the  upper  arm  should,  as  a  rule,  include  a  spica  of 
the  shoulder,  the  turns  of  which  cross  above  the  shoulder  and 
pass  under  the  opposite  arm.  A  bandage  of  the  thigh  will  require 
a  spica  of  the  hip  to  make  it  secure,  the  turns  passing  about  the 
lower  abdomen.  Strips  of  adhesive  plaster  may  at  times  be 
used  to  advantage  to  make  a  bandage  secure,  and  the  free  use 
of  safety  pins  at  points  where  the  folds  are  apt  to  slip  is  to  be 
recommended.  Retention  bandages  for  the  wrist  and  lower  fore- 
arm should  include  the  hand  but  leave  out  the  fingers  and  thumb. 
The  elbow  should  be  bandaged  in  the  position  in  which  it  is  to 
remain,  usually  flexed.  It  should  never  be  bandaged  in  the 
straight  position,  and  flexed  afterwards.  Even  a  slight  additional 
flexion  of  the  elbow  after  a  bandage  has  been  applied  may  cause 
dangerous  constriction.  In  bandaging  the  feet,  the  heel  where 
it  rests  upon  the  bed  should  be  protected  by  a  ring  pad. 

IX.  PLASTER-OF-PARIS  BANDAGES  AND  CASTS 

The  Plaster=of=Paris  Bandage. — The  materials  for  these 
bandages  will  consist  of  a  good  quality  of  dental  plaster  and  a 
rather  wide  meshed  gauze  or  preferably  crinoline  cut  into  strips 
of  the  requisite  width,  usually  2J/2  to  4  inches.  The  plaster  should 
be  very  finely  ground,  should  feel  very  smooth  to  the  fingers 
and  absolutely  free  from  grit.  It  should  "  set  "  within  ten  or 
fifteen  minutes.  The  best  material  for  the  bandages  consists  of 
white  crinoline  such  as  is  used  by  dressmakers,  with  a  mesh  of 
about  28  threads  to  the  inch.  If  a  cheap  quality  of  crinoline 
is  used  containing  an  excess  of  dextrine  in  the  starch  the  bandages 
will  not  set. 

Plaster  bandages  must  be  rolled  by  hand  for  the  reason  that 
they  must  be  so  loosely  rolled  that  when  immersed  in  water  they 
will  become  rapidly  and  completely  saturated.  A  machine- 
rolled  plaster  bandage  will  always  be  too  tight.  The  core  of  the 
bandage  should  be  an  open  cylinder  the  size  of  the  finger.  To 
prepare  them  properly  the  crinoline  is  cut  on  a  thread  to  the 
requisite  width  and  rolled,  in  ten-yard  lengths.  On  a  flat  table 
or  board  a  quantity  of  dry  plaster  and  a  spatula  are  placed. 


BANDAGING 


131 


FIG.  GO. — Method  of  squeezing  water  from  bandage.      (Eliason's  Practical  Bandaging.) 


Fio.  67.— Making  plaster  bandages.   (Eliason'a  Practical  Bandaging.) 


132 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


BANDAGING  133 

The  crinoline  bandage  is  placed  on  the  table  and  unrolled  for  a 
distance  of  about  a  quarter  of  a  yard,  with  the  free  end  toward 
the  operator.  Into  this  length  of  crinoline  lying  flat  upon  the 
table  a  sufficient  quantity  of  plaster  is  rubbed  with  the  spatula 
to  fill  all  the  meshes  evenly.  The  free  end  is  now  turned  into  a 
cylinder  about  one  inch  in  diameter,  and  is  rolled  across  the 
table  nearly  as  far  as  the  plaster  filling  extends;  it  is  then  drawn 
back  toward  the  operator  and  another  length  unrolled.  This  is 
in  turn  impregnated  with  plaster  and  the  same  process  continued 
until  the  whole  bandage  is  completed.  Before  beginning  to  roll 
each  successive  length  the  nurse  should  slide  the  impregnated 
roll  one  inch  forward  on  the  length  of  crinoline  lying  flat  upon  the 
table,  thus  insuring  loose  rolling.  If  this  is  not  done  the  bandage 
will  be  too  tight.  A  time-saving  method  consists  in  impreg- 
nating and  rolling  the  entire  width  of  the  crinoline  at  one  opera- 
tion, the  long  roll  being  afterwards  cut  into  suitable  lengths 
(Fig.  66).  The  completed  bandages  should  be  secured  with  pins, 
wrapped  in  thin  paper  and  stored  in  a  tin  pail  containing  a  small 
quantity  of  loose  plaster  and  fitted  with  an  air-tight  cover. 

Materials  to  be  assembled  for  a  plaster  cast  include:  a  rubber 
sheet  to  protect  the  bed,  rubber  gloves  and  gown  for  the  surgeon; 
rolls  of  cotton  sheet  wadding;  stockinet,  or  flannel  bandages  for 
padding;  harness  makers'  felt  for  protection  of  bony  prominences; 
gauze  and  plaster  bandages  and  a  basin  of  tepid  water. 

When  the  bandages  are  to  be  used  they  are  placed  on  end, 
one  after  another  as  required,  in  a  basin  of  water  till  air  bubbles 
cease  to  appear.  Each  bandage  as  needed  is  lifted  out,  wrung 
fairly  dry  (Fig.  67),  all  ra veilings  removed,  the  free  end  separated 
from  the  roll  and  the  bandage  handed  to  the  surgeon.  Not  more 
than  one  or  two  bandages  at  the  most  should  be  in  the  water  at 
the  same  time.  The  water  should  be  warm  and  deep  enough  to 
immerse  the  bandages  completely.  Care  must  be  taken  that  no 
water  is  accidentally  sprinkled  into  the  container  in  which  the 
unused  dry  bandages  are  stored.  The  removal  of  a  plaster  cast 
after  it  has  set  and  dried  is  a  somewhat  tedious  task  at  best. 
Various  instruments  have  been  devised  for  this  purpose  (Fig. 
68).  The  best  means  is  a  heavy-bladed  knife.  The  operation 
is  much  easier  if  the  line  along  the  plaster  cast  where  it  is  to  be 
cut  is  softened  with  vinegar  or  other  diluted  acid. 


CHAPTER  IX 
FRACTURES 

1.  The  Treatment  of  Fractures. — The  duties  of  the  nurse  in 
connection  with  fracture  cases  will  include  the  preparation  and 
assembling  of  articles  and  apparatus  required,  the  rendering  of 
such  assistance  as  may  be  called  for,  and  observation  of  the  case 
after  the  fracture  has  been  "put  up,"  particularly  for  the  first 
twenty-four  hours.  That  she  may  do  these  things  understand- 
ingly  the  general  principles  involved  in  the  treatment  of  fractures 
will  be  briefly  stated,  followed  by  an  enumeration  of  the  articles 
needed,  and  a  description  of  the  standard  forms  of  apparatus 
employed. 

The  most  important  factor  in  the  fracture  problem  is  the  ac- 
tion of  the  muscles  which  surround  the  fracture,  and  those  having 
their  attachments  at  points  on  either  side  of  it.  The  skeletal 
muscles,  besides  their  intermittent  action  in  response  to  the  will, 
have  a  continuous  action  which  is  under  an  ordered  control  of 
which  we  are  not  conscious.  Thus  the  head  is  held  upright,  the 
body  maintains  an  erect  position,  and  the  several  joints  are  not 
flaccid  but  maintained  under  a  certain  tension  by  the  balanced 
contractions  of  antagonistic  muscle  groups.  When  a  fracture  has 
occurred  this  tension  of  the  muscles  causes  the  broken  ends  to 
override  each  other,  and  since  the  normal  control  is  not  adapted 
to  this  new  false  joint,  a  distortion  takes  place  as  the  result  of  ex- 
cess of  power  of  one  antagonistic  muscle  or  group  of  muscles 
over  another ;  moreover  a  spasmodic  contraction  is  caused  by  the 
stimulus  of  the  injury,  in  an  attempt  to  keep  the  parts  still,  and 
this  spasm  is  exaggerated  by  attempts  to  reduce  the  fracture. 
There  are  therefore  two  things  to  be  done  in  the  treatment  of  a 
fracture.  (1)  To  stretch  out  the  contracted  muscles  until  the 
broken  ends  of  the  bone  can  be  replaced  in  normal  position;  or 
sometimes  to  relax  the  muscles  which  produce  distortion  by 
flexing  or  extending  one  of  the  adjacent  joints.  (2)  To  hold  the 
parts  in  correct  alignment  by  surrounding  them  with  a  rigid 
support.  The  joints  on  both  sides  of  the  fracture  must  also  be 
immobilized  as  a  rule.  When  the  fractured  ends  can  be  made  to 
engage,  so  that  they  do  not  slip  again,  the  traction  need  only  be 
134 


FRACTURES  135 

applied  at  the  time  the  fracture  is  put  up;  when  the  ends  continue 
to  slip,  traction  must  be  continued  until  consolidation  has  taken 
place.  The  position  of  the  joints  in  fixation  is  a  matter  of  im- 
portance, and  it  is  desirable  for  the  nurse  to  understand  this, 
since  at  times  vigilance  must  be  exerted  to  maintain  the  proper 
position  during  treatment.  The  following  are  the  usual  correct 
positions  for  immobilizing  the  several  joints  in  fracture  cases. 
The  hand  dorsi-flexed,  the  elbow  flexed,  the  shoulder  abducted, 
the  foot  at  right  angles  to  the  leg  and  adducted,  the  knee  straight 
or  slightly  flexed,  the  hip  abducted.  These  positions  must  be 
modified  in  special  cases.  In  putting  up  a  compound  fracture 
provision  must  be  made  for  access  to  the  wound.  In  many  com- 
pound fractures,  and  in  simple  fractures  when  a  large  artery  or 
nerve  trunk  is  wounded,  or  when  the  fracture  cannot  be  reduced 
or  kept  in  position  otherwise,  an  open  operation  must  be  done. 
The  time  required  for  the  healing  of  a  fracture  is  usually  about 
six  weeks.  It  varies  with  the  nature  and  seat  of  the  fracture  and 
with  the  age  of  the  patient.  In  children  it  is  much  less. 

Attempts  at  reduction  of  a  fracture  may  often  be  delayed  a 
day  or  two  for  several  reasons,  such  as  the  presence  of  a  con- 
dition of  shock,  or  of  excessive  swelling  of  the  parts ;  the  necessity 
of  taking  and  examining  X-ray  pictures ;  and  the  need  of  prepara- 
tion for  a  general  anaesthetic.  In  case  of  delay  the  fracture  must 
be  temporarily  immobilized  by  some  suitable  appliance.  Tem- 
porary fixation  may  be  done  in  the  ward  without  any  attempt  to 
secure  proper  position  of  the  fragments.  When  reduction  of  the 
fracture  is  to  be  attempted  it  will  usually  be  done  in  the  operating 
room  under  an  anaesthetic. 

2.  Traction  and  Fixed  Extension. — Consider  what  follows  in 
its  application  to  a  fracture  of  the  thigh.  The  same  principles 
apply  to  traction  for  other  fractures.  There  are  two  methods  for 
overcoming  muscular  contraction;  (1)  By  weights  and  pullies, 
making  continuous  traction;  (2)  by  forcibly  stretching  the  con- 
tracted muscles  under  an  anaesthetic,  to  the  required  point,  and 
holding  them  at  that  point  by  a  rigid  fixation.  To  secure  an 
efficient  grasp  of  the  limb  in  making  traction,  when  it  must  be 
continued  for  a  considerable  time,  it  is  necessary  to  distribute  the 
grasp  over  a  wide  surface,  for  a  narrow  grasp  (e.  g.,  a  loop  about 
the  ankle),  becomes  intolerable,  with  the  strong  pull  necessary, 
after  even  a  few  minutes. 

For  this  reason  traction  is  made  by  means  of  a  strong  fabric 


136  MINOR  TECHNIC  IN  SURGICAL  NURSING 

which  is  made  to  adhere  to  the  skin  over  as  wide  an  area  as  the 
conditions  permit.  Zinc  oxide  plaster  is  commonly  preferred. 
It  adheres  at  once  and  is  less  irritating  than  the  heavier  "  mole- 
skin "  plaster.  When  the  latter  is  used  it  must  be  slightly  warmed 
before  being  applied.  The  skin  should  be  cleansed  with  soap 
and  water,  shaved,  washed  with  alcohol  followed  by  ether  and 
dried  before  the  adhesive  is  applied.  The  scarcity  and  high 
cost  of  adhesive  plaster  led  to  the  use,  in  the  field  hospitals  in 
France,  of  several  forms  of  adhesive  paste,  by  which  strips  of 
suitable  fabric  could  be  glued  to  the  skin  (Sinclair's  Glue,  page 
177).  The  method  has  advantages  other  than  its  cheapness. 
It  is  time-saving;  it  is  less  irritating  and  gives  a  more  secure  hold 
than  the  adhesive  plaster ;  it  allows  perspiration  to  take  place,  pre- 
venting the  skin  from  becoming  sodden.  The  skin  is  not  shaved. 
It  is  washed  with  ether,  or  an  alkaline  solution  (bicarbonate  of 
soda,  4  drams  to  the  pint),  to  remove  the  oil,  and  dried.  The  glue 
is  melted  over  a  water  bath,  allowed  to  cool  sufficiently,  and  ap- 
plied to  the  skin,  brushing  up  the  hair  with  a  gauze  swab  on  a 
clamp.  The  traction  strips,  made  of  flannel,  flannellette,  or 
gauze  folded  4-ply,  with  webbing  straps  sewed  to  the  ends,  are 
applied  to  the  glued  surface  and  fixed  with  a  bandage.  The 
weights  by  means  of  which  traction  is  maintained  are  connected 
with  the  adhesive  strips,  after  they  are  placed  in  position  on  the 
limb,  by  cord  and  pulley  in  one  of  several  ways  in  accordance  with 
the  preference  of  the  individual  surgeon  or  with  the  standardized 
method  in  use  at  the  hospital. 

Fixed  extension  may  be  illustrated  by  the  application  of  the 
Thomas  splint.  This  beautifully  simple  and  efficient  apparatus 
was  long  used  in  the  treatment  of  tuberculous  hip  and  knee 
joints,  and  was  applied  by  Sir  Robert  Jones  to  the  treatment  of 
fractures  from  the  middle  of  the  leg  to  the  upper  thigh.  The 
illustration  explains  it  better  than  a  description  can  (Fig.  69). 
The  padded  ring  at  the  upper  end  of  the  splint  rests,  when  in  po- 
sition, against  the  tuber  ischii,  where  the  weight  of  the  body  is 
normally  borne  in  the  sitting  position.  It  permits  of  a  surprising 
freedom  of  motion  to  a  patient  with  a  fractured  thigh.  In  the 
war  zone  it  abolished  pain  in  the  transportation  of  these  most 
difficult  cases,  and  it  thereby  reduced  the  mortality  in  compound 
thigh  fractures  to  an  extent  that  can  hardly  be  estimated.  The 
nurse  in  attendance  must  remember  certain  points.  Pressure  on 
the  ischium  will  be  considerable  at  first.  It  may  be  relieved  by 


FRACTURES  137 

lifting  or  lowering  the  foot  of  the  splint,  or  swinging  it  inward  or 
outward,  and  particularly  by  frequently  shifting  the  skin  where  it 
is  under  pressure  from  the  ring.  The  patient  himself  soon  learns 
to  do  this.  The  skin  also  should  be  kept  dry  and  well  powdered. 
The  lower  end  of  the  splint  must  be  suspended  or  elevated  on  a 
support,  to  prevent  pressure  on  the  heel;  and  the  foot  must  be 
kept  at  a  right  angle  to  the  leg.  For  this  purpose  two  movable 
brackets  are  supplied  with  the  splint.  These  project,  one  up  and 
one  down,  at  right  angles  to  the  side  bars,  below  the  level  of  the 
foot.  A  modified  splint  of  this  form  has  been  used  for  extension 
of  the  arm. 

Fixed  extension  may  be  accomplished  by  forcible  extension 


FIG.  69.— The  Thomas  Splint. 


on  the  fracture  table,  or  by  other  mechanical  means,  and  putting 
on  a  plaster  cast  adapted  to  hold  the  fracture  in  position. 

3.  Splints. — (1)  Materials  and  Varieties. — A  splint  is  any 
apparatus,  made  of  rigid  material,  designed  to  fix  in  immobility 
the  part  of  the  body  to  which  it  is  applied.  Splints  when  properly 
applied  must  prevent  all  motion ;  must  not  slip ;  must  not  produce 
undue  pressure  anywhere,  or  interfere  with  the  circulation  of  the 
part.  We  may  distinguish  three  classes  of  splints,  (a)  Flat, 
straight  splints,  or  those  roughly  shaped  to  fit  the  part,  usually 
made  of  wood  or  metal ;  (b)  moulded  splints,  made  of  plastic  mate- 
rial, applied  while  soft  and  allowed  to  harden  in  position,  so  that 
they  fit  accurately  all  the  contours  of  the  part;  (c)  splints  which, 
like  the  Thomas,  are  designed  to  secure  immobilization  with  fixed 
extension.  Flexible  wooden  splints,  of  the  thinness  of  veneer, 
are  used  by  surgeons  for  many  purposes.  They  can  be  broken  or 
cut  with  scissors  to  any  convenient  shape  and  used  singly  or  in 
several  thicknesses  as  desired.  Rigid  wooden  splints,  from  ig 
to  %  inch  thick,  may  be  cut  with  a  knife  or  saw  to  fit  any 
particular  case,  and  separate  pieces  may  be  fitted  together, 
when  necessary,  with  nails,  screws  or  brackets.  Metal  splints 
may  be  of  wire  or  sheet  metal.  Many  forms  are  manufactured  in 
various  shapes  and  sizes  ready  for  use.  Moulded  splints  may  be 


138  MINOR  TECHNIC  IN  SURGICAL  NURSING 

made  of  plaster-of -Paris  by  folding  plaster  bandages  to  the  req- 
uisite thickness,  moulding  on  the  limb  and  allowing  to  set  in 
position.  Various  other  plastic  materials  may  be  employed. 
Extension  splints  are  usually  made  of  heavy  (^{6  in.)  steel  wire, 
forming  side  bars,  rigidly  connected,  and  bent  to  the  shape  re- 
quired. In  enumerating  some  of  the  many  forms  of  splints  it 
will  be  best  to  take  them  in  order  according  to  the  part  to  which 
they  are  applied. 

(2)  Splints  for   the    Upper  Extremity. — The   hyperextension 
hand  or  " cock-up"  splint  fits  the  wrist  and  palm  of  the  hand. 
It  is  shaped  to  hold  the  wrist  bent  backward,  in  order  to  preserve 
the  grasp  of  the  fingers,  in  injuries  of  the  hand  and  wrist.    For 
fractures  of  the  forearm  two  splints,   anterior  and  posterior, 
(dorsal  and  palmar)  will  be  called  for.    They  may  be  of  flat  wood, 
properly  padded,  or  of  thin  metal,  gutter  shaped  to  fit  the  curve 
of  the  arm  (Jones) .    Splints  including  the  elbow  usually  fix  it  at  a 
right  angle,  fitting  the  back,  front  or  inner  side  and  are  called 
internal,  anterior  or  posterior  angular  splints.    Several  forms  of 
abduction  and  extension  splints  for  the  upper  arm  and  shoulder 
have  proved  so  valuable  in  war  surgery  that  their  use  will  cer- 
tainly be  continued  in  civil  practice. 

(3)  For   the  Lower   Extremity. — A    posterior   leg    and    foot 
splint  fits  the  back  of  the  leg  and  has  a  piece  at  right  angles  to 
this  which  rests  against  the  sole  of  the  foot.     It  may  extend  to 
the  knee  or  to  the  middle  of  the  thigh.     It  may  consist  of  a  wire 
frame  wound  with  bandage   (Cabot's),  or  it  may  be  made  of 
woven  wire  or  wood.     A  wooden  splint  of  this  form,  fitted  with 
grooves  on  the  under  side  to  slide  on  a  flat  board  or  frame  resting 
on  the  bed,   is  known  as  Volkmann's  sliding  rest,  and  is  used 
when  extension  is  applied  to  fractures  of  the  thigh. 

A  posterior  knee  or  ham  splint  is  a  splint  fitting  the  leg  and 
thigh  back  of  the  knee  with  the  object  of  immobilizing  that  joint. 
It  may  be  made  of  a  straight  piece  of  wood  about  twenty  inches 
long  and  four  inches  wide,  well  padded,  or  it  may  (better)  be 
of  wood  or  metal  shaped  to  fit  the  curves  of  the  leg.  The  Listen, 
or  long  side  T-splint  is  a  long  wooden  splint  applied  to  the  side 
of  the  body  extending  from  the  foot  to  the  axilla,  used  in  cases 
of  fracture  of  the  thigh  and  pelvis.  It  has  a  short  cross-piece 
nailed  at  a  right  angle  to  the  lower  end  to  keep  it  from  turning. 
For  an  adult  it  will  be  about  four  feet  ten  inches  long,  four  inches 
wide  and  %  of  an  inch  thick.  Coaptation  splints  are  short,  nar- 


FRACTURES  139 

row  wooden  splints  which  are  laid  close  together  about  the  cir- 
cumference of  a  limb  and  held  by  straps  in  order  to  exert  equal 
pressure  from  all  sides.  They  are  applicable  only  to  the  upper 
arm  and  thigh,  where  but  a  single  bone  exists,  never  to  the 
forearm  and  leg.  They  are  always  used  in  conjunction  with 
other  apparatus.  Extension  splints  in  common  use  for  frac- 
tures of  the  femur  are  the  Blake  splint,  a  modification  of  the 
Thomas,  and  Hodgen's  splint,  which  acts  on  a  different  principle, 
suspending  the  leg  and  making  traction  by  means  of  the  weight 
of  the  body. 

(4)  Padding  Splints. — The  materials  for  padding  are  cotton 
wadding  (preferably  that  sold  by  the  trade  under  the  name  of 
hospital  wadding,  which  has  a  double  glazed  surface),  felt,  folded 
towels  and  sheets,  with  adhesive  plaster  and  bandages  to  fix  the 
pad.  Felt  is  the  best  material  to  pad  splints  but  also  the  most 
expensive.  Toweling  is  used  for  certain  special  pads  and  some- 
times to  pad  temporary  splints  in  emergency.  For  a  straight 
wooden  splint  six  or  more  thicknesses  of  hospital  wadding  are 
cut  or  folded  to  make  a  pad  large  enough  to  project  a  half  inch 
over  the  edge  of  the  splint.  The  pad  is  fixed  to  the  splint  with 
three  narrow  strips  of  adhesive  plaster  and  the  whole  covered 
neatly  with  a  gauze  roller  bandage  or,  better,  with  a  single  piece 
of  cotton  cloth  stretched  smoothly  over  the  padded  splint  and 
neatly  stitched  in  place.  A  ham  splint  must  have  extra  padding, 
2  inches  thick,  under  the  knee.  All  the  flat  wooden  splints 
should  be  padded  to  fit  the  limb,  that  is,  the  padding  should 
be  made  thicker  where  needed  to  fit  the  hollows.  It  is  better 
when  possible  to  do  the  fitting  on  the  sound  side  in  order  to 
avoid  unnecessary  handling  of  the  fractured  limb.  In  padding 
splints  the  body  prominences,  such  as  those  at  the  wrist,  elbow, 
ankle  and  heel,  must  be  particularly  looked  after.  Pressure  on 
these  points,  even  if  continued  only  for  a  few  hours,  may  result 
in  sloughing  of  the  skin.  The  splints  must  be  cut  away  over  these 
points  or  the  padding  adjusted  to  guard  them.  The  heel  is  par- 
ticularly susceptible  where  it  rests  on  the  bed,  carrying  part  of 
the  weight  of  the  foot  and  leg.  For  protection  of  the  heel  the 
ring  or  " doughnut"  pad  must  be  used  with  every  form  of  splint 
or  plaster  cast  applied  to  this  region.  This  pad  is  made  of  cotton 
wound  with  a  narrow  gauze  bandage.  It  is  exactly  the  size  and 
shape  of  the  common  doughnut. 

A  folded  towel  is  used  to  pad  coaptation  splints.    The  towel 


140  MINOR  TECHNIC  IN  SURGICAL  NURSING 

is  folded  in  four  to  eight  thicknesses  and  wrapped  smoothly  about 
the  limb.  The  coaptation  splints,  narrow  pieces  of  thin  wood  one 
inch  wide,  are  then  laid  over  the  towel  and  strapped  in  place. 

(5)  Materials  for  Fastening  Splints. — Straps  of  webbing,  one 
inch  wide  with  a  buckle  sewed  to  one  end,  or  strips  of  adhesive 
plaster  one  to  two  inches  wide,  and  long  enough  to  encircle  the 
limb  and  splints  one  and  a  half  times,  are  used  for  this  purpose. 
A  roller  bandage  of  gauze  or  muslin  is  usually  applied  over  the 
whole  for  additional  security  and  protection.  There  is  sometimes 
a  little  difficulty  in  passing  the  strip  of  sticky  adhesive  plaster 
under  and  about  the  limb  without  becoming  twisted  and  kinked 
before  it  has  been  properly  adjusted.  This  minor  annoyance 
can  be  easily  prevented  by  a  very  simple  expedient.  A  piece 
is  cut  from  a  roller  bandage  twice  the  length  of  the  adhesive 
strip,  folded  end-to-end  and  laid  on  the  adhesive  side  of  the  strip. 
The  whole  is  next  passed  under  and  about  the  limb  and  adjusted 
to  the  proper  position.  The  bandage  is  then  removed  by  pulling 
on  the  free  end.  The  end  of  the  adhesive  strip  should  be  folded 
on  itself  for  a  quarter  of  an  inch  to  facilitate  removal. 

4.  Accessory  Apparatus  (1)  The  Fracture  Table. — This  is  a 
special  operating  table  designed  to  make  fixed  extension,  partic- 
ularly of  the  thigh,  while  a  plaster  cast  is  being  applied,  or  to 
facilitate  open  operation  in  fracture  cases. 

(2)  The  Fracture  Bed. — This  consists   of  a  rigid  frame  to 
support  the  mattress.    A  fracture  of  the  thigh  or  pelvis  can- 
not   be   treated   properly  on  a   bed    that  sags.     Four  1   inch 
boards,  as  long  as  the  bed  is  wide,  with  cleats  nailed  to  the 
ends  to  prevent  slipping,  are  placed  across  the  bed  frame,  under 
the  wire  springs. 

(3)  The  Bradford  Frame. — This  is  a  rectangular  frame,  6 
feet  long  and  16  inches  wide,  made  of  %  mch  gas-pipe.     It  is 
covered  with  canvass,  laced  on  in  two  pieces,  leaving  a  separation 
of  5  inches  for  use  of  the  bed  pan.    It  is  used  for  spinal  and  pelvic 
fractures  requiring  fixation  in  recumbency.     Smaller  sizes  are 
used  for  fracture  and  orthopaedic  cases  in  children. 

(4)  The  Balkan  Frame. — Patients  with  severe,  multiple  or 
compound  fractures,  who  must  be  confined  to  bed  for  a  long  time, 
suffer  greatly  from  the  mere  inertia  of  the  injured  limb,  with  its 
heavy  fixation  or  extension  appliance.    It  lies  as  a  dead  weight, 
and  it  anchors  the  whole  body  in  one  position,  from  which  the 
patient  can  move  only  a  little,  and  after  weary  waiting  for  the 


FRACTURES 


141 


help  of  busy  attendants.  What  a  blessing  if  the  limb  with  its  en- 
cumbrance could  be  made  light,  made  to  float  in  the  air,  responding 
easily  to  every  movement  of  the  body !  The  answer  is  the  Balkan 
frame  (Fig.  70) .  Long  in  use  in  primitive  form  it  was  developed 
in  the  Balkan  war  and  perfected  in  the  Base  Hospitals  in  France. 
Adjustments  without  number  can  be  made  with  it,  balancing  the 
fracture  apparatus  by  means  of  weights  and  pulleys,  exerting 
traction  in  any  desired  direction,  and  -  giving  the  patient  an 
amazing  freedom  of  movement  without  interfering  in  any  way  with 
his  fixation  apparatus. 

5.  Materials  to  be  Assembled  for  a  Fracture  Dressing.— 
Soap  and  water,  alcohol  and  talcum  powder  for  the  preliminary 


FIG.  70. — The  Balkan  Frame. 

cleansing;  the  particular  forms  of  splints  called  for  by  the  sur- 
geon; abundant  materials  for  padding  (sheet  wadding,  felt, 
towels);  adhesive  plaster;  gauze  and  muslin  bandages  and  safety 
pins,  will  be  needed  in  all  cases.  For  traction  extension  of  the 
thigh  (Buck's  extension)  there  will  be  required  in  addition: 
weights  up  to  20  Ibs;  4  feet  of  window  cord;  a  pulley  with  ar- 
rangement to  attach  it  to  the  foot  of  the  bed;  the  "spreader"; 
blocks  to  raise  the  foot  of  the  bed  six  inches;  4  webbing  straps 
two  feet  long  with  buckles;  several  yards  of  muslin  or  Shaker 


142  MINOR  TECHNIC  IN  SURGICAL  NURSING 

flannel  to  make  swathes  to  encircle  the  pelvis  and  chest;  extra 
towels  and  sheets ;  2  long  narrow  sandbags  and  a  cradle,  to  keep 
off  the  weight  of  the  bedclothes.  The  splints  required  will  be  the 
long  T-splint,  coaptation  splints  and  a  ham  splint  or  a  Volkmann's 
sliding  rest.  The  spreader  is  a  piece  of  wood  4  by  3  by  %  inches, 
with  a  y±  inch  hole  in  the  center,  through  which  the  cord  attached 
to  the  weights  is  passed  and  knotted.  It  is  placed  below  the  sole 
of  the  foot  and  prevents  the  traction  straps  from  pressing  on  the 
ankle  bones. 

6.  Observation  After  Dressing  of  Fractures. — All  fracture 
cases  must  be  closely  watched  for  at  least  the  first  twelve  hours 
after  a  fixation  dressing  is  applied.  Continued  pain  at  the  seat 
of  fracture  or  over  a  bony  prominence  calls  for  serious  attention 
from  the  surgeon.  Blueness  and  coldness  of  the  extremities 
below  the  bandage  (fingers  and  toes),  with  or  without  swelling, 
calls  for  instant  relief  of  pressure,  even  to  the  extent  of  cutting 
through  the  whole  bandage  down  to  the  skin.  When  extension 
by  means  of  weights,  in  thigh  fractures,  is  employed,  the  patient 
is  apt  to  slide  down  until  his  foot  rests  against  the  foot  of  the  bed 
relieving  him  of  the  weight.  The  nurse  must  be  on  the  watch  to 
correct  this  and  must  also  report  it  to  the  surgeon. 


CHAPTER  X 

REMEDIAL  MEASURES 
I.  MEASURES  REQUIRING  SIMPLE  CLEANLINESS 

IN  the  preparatory,  post-operative  and  routine  treatment  of 
gynaecological  patients,  there  are  a  number  of  measures  for  the 
relief,  cure  or  comfort  of  the  patient  that  do  not  require  the 
strictest  technic, — and  it  seems  fitting  that  these  should  receive 
consideration  in  a  separate  group,  so  that,  by  no  chance,  could 
they  be  extended  to  include  those  of  a  stricter  order. 

1.  The  enema  has  already  been  referred  to  upon  several 
occasions  in  its  connection  with  preparatory  and  after-treatment. 
While  the  average  enema  does  not  require  adherence  to  the  most 
careful  technic  in  its  administration,  it  must  be  realized  that 
this  leeway  does  not  admit  of  careless  or  unclean  methods.  The 
enema  can,  tube  and  tip  should  be  cleansed  by  mechanical  methods 
after  each  use.  The  tip  should  be  sterilized  as  well  as  mechanically 
cleansed  before  putting  away.  This  is  particularly  true  in  hospital 
work,  where  a  large  series  of  patients  must  necessarily  include 
some  from  whom  dangerous  infections  might  be  transferred  to 
innocent  persons  if  these  precautions  were  not  taken.  In  per- 
forming the  manipulations  necessary  for  the  administration  of 
an  enema,  it  should  not  be  forgotten  that  there  is  as  much  a 
right  and  wrong  way  of  doing  this  as  of  any  other  treatment. 
There  seems  to  exist  in  some  minds  the  impression  that  giving 
an  enema  means  taking  a  can  with  the  usual  accessories;  filling 
with  the  prescribed  solution;  inserting  the  tip;  lifting  the  can  to 
the  extreme  limit  of  the  tube  or  of  the  nurse's  arm;  removing  the 
tip;  and  going  off  and  leaving  the  patient  upon  a  bed-pan  until 
it  is  convenient  to  remove  the  same.  Strange  as  it  may  seem, 
there  are  several  fallacies  in  these  conclusions.  There  are  a 
number  of  elements  that  enter  into  the  use  and  administration 
of  enemata  that  should  be  considered  before  the  subject  is  referred 
to  the  limbo  as  one  of  no  difficulty  and  little  importance.  In 
the  first  place,  there  are  at  least  three  positions  in  which  enemata 
may  be  administered,  according  to  the  result  desired  and  the 
preference  of  the  attendant:  the  dorsal,  the  left  lateral  and  the 

143 


144 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


knee-chest.  No  matter  what  the  position,  the  general  details 
followed  in  each  case  are  very  much  the  same.  The  enema 
formula  is  prepared  in  the  can.  The  patient  is  placed  in  the 
desired  position  and  the  tip  inserted  with  the  aid  of  a  little  vase- 
line or  other  lubricant.  The  passage  of  the  rectal  or  colon  tube, 
while  of  apparent  simplicity,  may  be  done  in  such  a  way  as  to 
add  much  to  the  discomfort  of  the  patient  and  the  difficulty  of 
the  procedure.  The  general  outline  and  direction  of  the  anal  and 
rectal  canals  (Fig.  71)  should  be  borne  in  mind  and  the  tip 


Rectum 


Anus 


FIG.  71. — Median  section  of  female  pelvis.   The  difference  in  direction  of  anus  and  rectum 

should  be  noted. 

directed  thus  along  the  line  of  least  resistance,  instead  of  forced 
in  a  straight  line.  This  means  that  the  tip  must  be  inserted  first 
in  an  anterior  direction  until  it  has  passed  the  sphincter  and  is 
in  the  rectum.  The  direction  is  then  changed,  the  tip  bsjng 
pointed  backward  and  passed  in  such  a  manner  a£  to  somewhat 
follow  the  curves  of  the  sacrum.  The  passing  of  the  ^colon  tube 
beyond  this  point  frequently  requires  considerable  .patience  anil 
ingenuity  of  manipulation.  The  sigmoid  leaving  the  -rectum  at 
an  angle  towards  the  left,  the  tube,  being  long  and  soft,  must  be 


REMEDIAL  MEASURES  145 

permitted  to  follow  the  course  of  the  bowel.  Kinking  and  doub- 
ling of  the  tube  in  the  rectum  will  generally  cause  complaint  of 
pain  by  the  patient  and,  should  this  not  be  the  case,  is  sure  to 
interfere  with  the  flow  of  the  solution.  The  colon  tube  is  best 
introduced  with  the  patient  in  the  left  lateral  position.  The 
enema  generally  does  not  exceed  one  quart  in  quantity, — and 
frequently  falls  short  of  that  amount.  The  fluid  should  not  be 
run  into  the  rectum  with  speed  and  the  highest  possible  hydro- 
static pressure,  but  should  be  allowed  to  run  in  slowly  with  the 
can  elevated  only  from  12  to  18  inches  above  the  patient.  Fur- 
thermore, when  there  is  any  possibility  of  intestinal  obstruction 
existing,  which  means  after  every  abdominal  section,  the  patient 
should  not  be  left  until  the  enema  is  expelled, — as  it  is  very 
important  that  the  passage  of  gas  be  noted  should  it  occur.  As 
this  may  happen  even  when  the  enema  returns  clear,  its  impor- 
tance should  be  manifest  to  every  one. 

Enemata  are  divided  into  several  classes,  according  to  the 
use  for  which  they  are  intended:  cleansing,  stimulating,  purga- 
tive and  nutrient  being  the  generally  accepted  descriptive  names 
applied. 

The  cleansing  enema  partakes  more  of  the  character  of  a 
washing,  or  irrigation,  of  the  lower  bowel,  consisting  of  hot 
water,  salt  solution  or  soapsuds.  It  is  usually  given  in  prepara- 
tion for  abdominal,  perineal  or  rectal  operation  to  clear  the  rectum 
of  such  food  detritus  as  remains  after  the  usual  catharsis,  or 
before  nutrient  enemata  in  order  to  clear  the  lower  bowel  for 
the  reception  and  absorption  of  the  food  material  introduced  by 
this  route. 

The  stimulating  enema  is  generally  composed  of  salt  solution, 
together  with  general  stimulants.  One  of  the  most  common 
consists  of  one  pint  each  of  hot  normal  salt  solution  and  strong, 
black  coffee.  Another  consists  of  ammonium  carbonate,  brandy 
and  salt  solution. 

The  purgative  enemaia  are  given  when  a  prompt  and  thorough 
evacuation  of  the  bowels  is  sought  and  the  simple  enema  proves 
inefficacious.  A  list  of  the  ingredients  utilized  in  the  preparation 
of  this  particular  class  of  enemata  would  very  nearly  resemble  a 
transcription  of  the  pharmacopoeia,  but  a  few  of  the  more  com- 
monly employed  are  magnesium  sulphate,  glycerine,  turpentine, 
alum  and  asafcetida.  A  small  and  usually  very  efficient  enema 
is  made  up  of  one  ounce  of  a  saturated  solution  of  magnesium 


146  MINOR  TECHNIC  IN  SURGICAL  NURSING 

sulphate,  two  ounces  of  glycerine  and  three  ounces  of  water  or 
soapsuds.  This  is  commonly  called  a  "  one,  two,  three  "  enema. 
Another  well-known  routine  purgative  enema  is  composed  of  the 
same  ingredients  in  larger  quantities  and  named  accordingly. 
This  is  the  "  two,  four,  eight  "  enema,  consisting  of  two  ounces 
of  a  saturated  solution  of  magnesium  sulphate,  four  ounces  of 
glycerine  and  eight  ounces  of  water  or  soapsuds.  Turpentine 
may  be  added  to  either  of  these  enemata,  in  varying  quantities — 
as  much  as  half  an  ounce  being  added  to  the  larger. 

Nutrient  enemata  are  given  when,  for  any  reason,  mouth 
feeding  must  be  temporarily  abandoned  and  the  condition  of 
the  patient  necessitates  the  continued  ingestion  of  supporting 
food.  On  account  of  rapidly  developing  irritability  of  the  larger 
bowel,  this  treatment  is,  at  best,  not  feasible  for  extended  periods. 
On  account  of  the  limited  digestive  capacity  of  the  large  bowel, 
the  range  of  nutriment  to  be  employed  is  necessarily  curtailed. 
Nutrient  enemata  must,  therefore,  be,  so  far  as  possible,  of  the 
most  readily  assimilable  and  the  most  slightly  irritating  possible 
ingredients.  The  most  common  ingredients  are  milk  (plain  or 
peptonized),  eggs,  sugar  (grape  or  cane),  red  wine  and  salt, — 
varying  in  proportion  to  make  a  maximum  total  quantity  of 
eight  or  nine  ounces.  One  of  the  simplest  is  the  sugar  and  milk 
enema,  consisting  of: 

Grape  sugar 60  gm. 

Peptonized  milk 250  c.c. 

A  more  complicated  one  is  that  of  Boas,  consisting  of: 

Milk 250c.c. 

Yolks  of  two  eggs 
Pinch  of  salt 

Red  wine 15  c.c. 

Starch  or  flour 15  gm. 

2.  Rectal  Irrigation. — There  is  very  little  to  be  said  of  rectal 
irrigation  that  has  not  already  been  referred  to  under  the  dis- 
cussion of  enemata.  The  preparation  of  rectal  irrigation  is  the 
same  as  that  for  the  enema,  except  for  the  substitution  of  a 
glass  or  enamel-ware  funnel  for  the  enema  can.  The  funnel  is 
then  filled  with  the  solution  that  is  to  be  used  and  the  solution 
run  into  the  rectum  by  elevating  the  funnel  to  the  necessary 
height.  This  proceeding  is  repeated  several  times,  until  the 
rectum  has  been  somewhat  distended  by  the  solution,  when  the 
funnel  is  lowered  and  permitted  to  fill  with  the  solution  running 


REMEDIAL  MEASURES  147 

back  from  the  rectum.  The  contents  from  the  funnel  are  then 
poured  into  a  receptacle  provided  for  the  purpose  and  the  process 
repeated,  time  and  again,  until  the  rectum  has  been  emptied. 
This  treatment  is  continued  until  the  rectum  has  been  cleansed, 
if  that  is  the  object  of  the  irrigation,  or  until  the  application 
has  been  sufficient  for  the  purpose  in  view,  whatever  it  may  be. 
In  addition  to  the  above  apparatus  and  method,  mention  might 
be  made  of  the  double-channel  rectal  or  colon  tube,  that  permits 
of  the  return  of  the  fluid  by  one  channel  as  fast  as  it  enters  by 
the  other. 

3.  Continuous  Proctoclysis  (Murphy  Method  for  Rectal  Salt 
Solution). — The  application  of  the  principles  of  this  method  of 
treatment  is  so  varied  with  different  physicians  and  in  different 
hospitals  that  it  would  take  a  small  book  to  go  into  the  details 
of  each  different  apparatus  and  the  method  of  using  it.  But  the 
end  to  be  attained  is  in  each  case  the  same,  so  that  a  general 
description  of  the  principles  involved  appears  proper  in  this  place. 

The  object  is  the  introduction  into  the  rectum  of  a  physio- 
logical salt  solution  at  the  temperature  and  rate  at  which  it  will 
be  most  rapidly  absorbed.  The  method  is  of  the  greatest  value, 
and  it  is  extremely  important  for  both  nurses  and  internes  to 
know  how  to  give  it  properly.  It  is  a  frequent  experience  of 
surgeons  when  ordering  this  treatment  to  have  it  reported  that 
the  patient  is  unable  to  retain  the  saline  solution,  and  this  is 
due  in  the  great  majority  of  instances  to  faulty  methods  of  admin- 
istration. The  requisites  are  (1)  that  the  fluid  should  be  warmed, 
(2)  that  it  should  flow  drop  by  drop,  about  one-half  pint  entering 
the  rectum  each  hour,  (3)  that  there  should  be  a  free  return  so 
that  when  the  rectum  contracts  the  gas  and  fluid  which  are 
present  may  flow  easily  back  through  the  tube  and  not  be  expelled. 
The  form  of  apparatus  first  suggested  by  Dr.  Wroth  (Fig.  72) 
is  the  simplest  and  best  and  can  be  readily  improvised  anywhere. 
A  glass  or  metal  funnel  is  connected  by  about  four  feet  of  rubber 
tubing  and  a  glass  connection  tube  with  a  small  or  medium-sized 
catheter.  The  catheter  is  introduced  into  the  rectum  and  fixed 
to  the  inner  side  of  the  thigh  by  a  strip  of  adhesive  plaster.  The 
funnel  is  suspended  by  the  side  of  the  bed  at  a  height  of  about 
6  to  14  inches  above  the  level  of  the  buttocks.  The  irrigator 
containing  the  saline  solution  is  suspended  above  the  funnel  and 
is  furnished  with  a  short  rubber  tube  terminating  in  a  stop-cock 
so  adjusted  that  the  fluid  can  be  allowed  to  flow  drop  by  drop 


148 


MINOR  TECHNIC  IN  SURGICAL  NURSING 


into  the  funnel.  The  fluid  is  warmed  just  before  it  enters  the 
rectum  by  placing  a  coil  of  the  tube  which  joins  the  funnel  and 
the  catheter  between  two  hot-water  bags  lying  on  a  table  beside 


Graduated  glass  container 
for  saline  solution 


Stop-cock  to  regulate   flow 
drop  by  drop 


Plain  glass  funnel  con- 
nected directly  with 
rectal  tube 


Rubber  tubing 


Glass  tube  connection 


Rubber  catheter  to  be 
introduced  into  rectum 


FIG.  72. — Apparatus  for  proctoclysis. 

the  bed.  About  60  to  80  drops  per  minute  is  the  proper  rate  of 
flow.  It  is  sometimes  difficult  to  regulate  the  flow  exactly.  To 
facilitate  this  a  shallow  notch  should  be  filed  at  the  edge  of  the 


REMEDIAL  MEASURES  149 

opening  through  which  the  water  flows  in  that  part  of  the  stop- 
cock which  is  turned  by  the  finger  and  thumb  (Fig.  73).  In  an 
improvised  outfit  the  tube  from  the  irrigator  may  be  compressed 
by  means  of  two  flat  sticks  and  rubber  bands,  the  sticks  being 
wedged  apart  to  regulate  the  flow. 

4.  Active  and  Passive  Congestion. — Several  methods  de- 
signed to  influence  the  flow  of  blood  to  a  part  are  frequently 
resorted  to  in  the  treatment  of  surgical  cases.  These  include  the 
use  of  moist  and  dry  heat,  constriction  of  arms  or  legs  by  rubber 
bands  to  induce  passive  congestion  by  obstructing  the  return 
flow  of  blood  through  the  veins,  and  the  use  of  cups  of  various 


--Nohch 


Fio.  73. — Showing  notch  filed  in  stop-cock  to  facilitate  regulation  of  rate  of  dropping. 

forms  in  connection  with  a  small  suction  pump  by  means  of  which 
passive  congestion  may  be  induced  in  parts  of  the  body  surface 
where  constriction  is  not  available.  The  application  of  heat  in 
either  moist  or  dry  form  causes  what  is  known  as  active  conges- 
tion; that  is,  it  induces  a  dilatation  of  the  small  arteries  and  pro- 
duces an  increased  flow  of  blood  to  the  part.  Moist  heat  is  applied 
by  means  of  hot  fomentations.  Dry  heat  is  applied  by  means 
of  hot  air.  The  arm  or  leg,  for  example,  is  wrapped  in  blankets 
and  placed  in  a  double-walled  chamber  or  oven  (supported  so 
that  the  limb  does  not  come  in  contact  with  the  walls  of  the 
chamber)  in  which  the  air  is  heated  by  means  of  a  gas  jet  up  to 
250°  or  300°  F.  Passive  congestion,  on  the  other  hand,  consists 


150  MINOR  TECHNIC  IN  SURGICAL  NURSING 

not  in  increasing  the  flow  of  blood  to  the  part,  but  in  allowing 
blood  to  accumulate  in  the  part  by  partly  obstructing  the  return 
flow,  and  the  methods  of  doing  this  by  means  of  constricting  bands 
and  cups  are  known  as  Bier's  hyperaemic  treatment,  employed 
in  acute  and  chronic  (tuberculous)  infection.  The  apparatus 
for  constricting  a  limb  consists  of  an  Esmarch  bandage  or  rubber 
tube  tourniquet  applied  over  a  smooth  folded  towel  wrapped 
about  the  limb.  The  treatment  is  intermittent,  the  constriction 
being  maintained  for  from  one  to  several  hours,  the  bandage 
being  then  removed  for  a  time  and  later  reapplied.  As  the  nurse 
may  at  times  be  entrusted  with  its  application  and  must  in  any 
case  observe  the  condition  of  the  limb  during  the  period  of  con- 
striction, it  is  important  for  her  to  bear  in  mind  the  following 
points.  The  band  should  be  applied  over  healthy  tissue  well 
above  the  seat  of  the  disease;  it  should  moderately  constrict  the 
veins  of  the  part,  so  as  to  diminish  but  not  stop  the  return  flow 
and  without  affecting  the  volume  of  the  pulse;  the  skin  below 
the  constriction  should  be  of  a  slightly  bluish-red  color  and 
warmer  to  the  touch  than  normal;  there  should  be  no  pain.  If 
there  is  much  swelling,  and  the  skin  is  blue  and  cold,  or  if  there 
is  pain,  then  the  constriction  is  too  tight  and  must  be  loosened 
or  removed  for  a  time.  It  is  better  to  change  the  location  of  the 
constriction  at  each  application.  A  great  variety  of  cups  are 
manufactured  for  the  production  of  local  hyperaemia  at  different 
areas  of  the  body  surface,  for  the  treatment  particularly  of  local 
infections,  such  as  furuncles,  carbuncles,  abscesses,  etc.  At  least 
two  or  three  sizes  of  some  of  the  simpler  forms  of  this  apparatus 
should  be  available;  for  the  application  of  this  method  the  proper 
cup  attached  with  rubber  tubing  to  a  rubber  bulb  or  small  hand 
pump  to  produce  suction,  and  some  sterile  vaseline  to  make  the 
edge  of  the  cup  air-tight,  will  be  needed.  In  this  case  the  hyper- 
aemia is  continued  for  short  intervals  only  (five  minutes)  at  a 
time,  with  five  to  ten  reapplications  at  each  treatment.  If  there 
is  a  wound  the  cup  must  be  sterilized  before  and  after  use. 

5.  Paraffin  OcclusionTreatmentfor  Burns. — A  method  of  treat- 
ing burns  by  a  covering  of  melted  wax  was  introduced  in  France 
by  Berthe  de  Sandford,  and  during  the  war  his  secret  preparation, 
called  "  Ambrine,"  became  widely  known  through  popular  articles 
in  the  newspapers.  Because  Ambrine  is  secret,  costly,  and  not 
easily  obtainable,  a  number  of  imitations  have  been  put  on 
the  market,  and  numerous  formulae  have  been  proposed.  Nearly 


REMEDIAL  MEASURES  151 

all  of  these  are  satisfactory  substitutes.  The  requisites  are  sim- 
ple; a  wax,  neutral  in  reaction,  which  will  adhere  to  the  skin  and 
be  sufficiently  flexible  not  to  crack  at  ordinary  temperatures. 
It  should  melt  at  about  115°  to  120°  F.  The  best  results  are  ob- 
tained with  a  mixture  of  waxy  substances  which  melt  at  different 
temperatures.  The  formula  proposed  by  Carrel  is  one  of  the 
best  (page  177).  Ambrine  itself  is  said  to  be  a  10%  mixture  of 
gutta-percha  with  paraffin. 

Burns  of  the  second  degree  and  clean  granulating  wounds  are 
suitable.  Infected  and  sloughing  areas  do  not  do  well  under  oc- 
clusion. In  fresh  burns  of  the  second  degree  the  blebs  may  be 
opened  and  drained  but  not  removed.  In  granulating  areas  se- 
cretions and  crusts  are  washed  off,  or  removed  with  dry  sponges. 
The  surface  must  then  be  dried,  best  by  an  electric  hot  air  blower, 
but  an  electric  or  ordinary  fan  may  be  used.  The  melted  wax, 
(at  140°  F.)  is  applied  directly  to  the  burn  and  a  margin  of 
skin  around  it.  It  is  best  done  by  a  special  spray  appar- 
atus, water  jacketed  or  electric  heated.  A  soft  brush  may  be 
used.  A  thin  layer  of  absorbent  cotton  is  then  applied  and 
impregnated  with  the  melted  wax.  Over  all  a  dry  cotton  dress- 
ing is  applied.  The  part  should  be  immobilized. 

6.  The  Fowler  Position. — After  certain  abdominal  operations, 
particularly  suppurating  appendix  cases,  it  is  desirable  to  place 
the  patient  in  bed  in  the  so-called  Fowler  position,  that  is,  in  a 
semi-sitting  posture,  at  an  angle  of  60°  to  70°,  and  to  do  this 
special  apparatus  must  be  provided.    One  of  the  best  is  known 
as  the  Gatch  bed,  an  iron  frame  placed  under  the  mattress  and 
capable  of  lifting  it  at  the  patient's  back  and  under  his  knees 
into  the  form  of  a  reclining  chair.    An  apparatus  may  be  impro- 
vised by  the  use  of  a  back  rest,  a  bolster  made  from  a  pillow  tightly 
rolled  in  a  sheet  placed  under  the  buttocks,  with  the  ends  of  the 
sheet  tied  to  the  bed  frame  to  prevent  the  patient  from  slipping 
down  in  the  bed,  a  rolled  pillow  as  a  brace  for  the  feet,  and  sup- 
porting pillows  under  the  knees. 

7.  Special  Forms  of  Dressings. — "Wet  dressings"  are  used  in 
the  treatment  of  infected  wounds,  and  particularly  spreading 
cellulitis,  which  often  follows  accidental  wounds  of  the  hand  or 
foot.    Absorbent  gauze  in  the  form  of  fluffs  and  rolls,  warm  boric 
acid  solution,  oiled  or  rubber  cloth,  non-absorbent  cotton,  towels 
and  bandages  will  be  needed.    Continuous  immersion  of  the  part 
in  a  basin  of  the  warm  solution  may  be  employed. 


152  MINOR  TECHNIC  IN  SURGICAL  NURSING 

Bismuth  paste  which  is  used  for  the  injection  of  sinuses  is  a 
mixture  of  subnitrate  of  bismuth  and  vaseline.  It  is  semisolid 
at  ordinary  temperatures,  and  must  be  liquefied  when  it  is  to 
be  used,  by  warming  over  a  water  bath.  A  sterile  glass  syringe 
of  suitable  size,  alcohol,  small  sterile  pads  of  gauze  and  adhesive 
plaster  will  be  required. 

Unna's  paste  (page  177)  is  used  in  the  treatment  of  leg  ulcers. 
A  quart  or  more  of  the  paste,  melted  over  a  water  bath,  a  medium- 
sized  paintbrush,  alcohol,  sponges  and  a  number  of  two-inch 
gauze  bandages  will  be  required. 

II.  ROUTINE  MEASURES  REQUIRING  ASEPTIC  TECHNIC 

In  addition  to  those  measures  executed  by  the  nurse  that 
have  already  been  enumerated  as  of  a  kind  requiring  mechanical 
cleanliness  alone,  there  are  several  that  demand  as  strict  an  asep- 
tic technic  as  any  of  the  procedures  of  major  surgery.  These 
are  generally,  if  not  always,  performed  by  the  nurse,  and  she 
should  constantly  bear  in  mind  her  responsibility  to  patient  and 
physician  for  the  proper  care  and  precautions  in  every  such  case. 

1.  Hypodermic  Medication. — We  have  already  made  some 
passing  reference  to  the  generally  accepted  inexcusability  of 
abscess  following  hypodermic  medication.  While  admitting  with- 
out hesitation  that  such  abscesses  will  occur  when,  apparently, 
every  possible  precaution  has  been  taken,  yet  the  fact  remains 
that  suspicion  of  the  care  and  technic  of  the  administrator  invari- 
ably follows  the  appearance  of  this  unfortunate  complication. 
The  technic  of  administration,  while  exacting,  is  of  the  simplest, — 
whence,  possibly,  the  carelessness  that  makes  the  occasional 
infection  a  possibility.  The  steps  are  four:  (a)  preparation  of 
the  syringe;  (6)  preparation  of  the  solution;  (c)  preparation  of 
the  patient;  and  (d)  administration  of  the  injection  of  the  medica- 
ment. The  division  of  such  a  simple  performance  into  parts 
may  seem  like  the  making  of  a  mountain  out  of  a  mole-hill,  but 
it  remains  true  in  nursing  as  it  has  of  all  admirable  branches  of 
the  world's  work  that  what  is  worth  doing  is  worth  doing  well. 

(a)  The  best  type  of  syringe  for  general  use  is  the  all-glass 
instrument  that  will  permit  of  the  instrument  being  repeatedly 
sterilized  by  boiling  and  permit  the  contents  to  be  seen.  It  is 
best  to  boil  the  entire  instrument  before  using,  but,  if  this  be 
not  feasible,  the  needle  should  be  boiled,  a  wire  being  kept  run 
through  the  lumen  to  prevent  clogging  by  rust. 


REMEDIAL  MEASURES  153 

(6)  A  small  amount  of  water  is  then  sterilized  by  boiling  over 
a  flame  in  a  teaspoon  or  other  convenient  receptacle.  The 
syringe  is  then  drawn  full  of  the  sterile  water  and  the  remainder 
thrown  away.  The  contents  of  the  syringe  are  then  once  more 
discharged  into  the  spoon  and  a  hypodermic  tablet  containing 
the  prescribed  dosage  of  the  medicament  is  dissolved  in  the  water 
and  the  solution  drawn  into  the  syringe. 

(c)  The  patient's  arm  is  then  scrubbed  with  a  sterile  gauze 
sponge  and  95  per  cent,  alcohol,  or  painted  with  tincture  of  iodine 
over  the  area  of  injection,  a  point  at  about  the  middle  of  the  upper 
arm  being  the  usual  point  of  election. 

(d)  A  small  bit  of  skin  is  then  pinched  up  between  the  thumb 
and  index  finger  of  the  left  hand  and  the  hypodermic  needle 
quickly  inserted.     The  needle  is  withdrawn  about  }%  of  an  inch 
and  the  solution  slowly  injected.     The  needle  is  then  slowly 
withdrawn,  the  point  of  injection  being  covered  and  then  lightly 
rubbed  with  the  alcohol-saturated  sponge. 

2.  Catheterization  of  Patient. — The  importance  and  responsi- 
bility of  this  procedure  have  already  been  touched  upon  in  our 
remarks  upon  post-operative  treatment.  We  shall,  therefore, 
confine  ourselves,  at  this  time,  chiefly  to  a  discussion  of  the  ideal 
technic  and  the  variations  thereof  that  are  commonly  resorted 
to  for  the  purpose  of  lessening  the  time  and  tedium  where  numer- 
ous catheterizations  are  necessary. 

The  outfit  for  catheterization  should  consist  of:  (a)  a  sterile 
glass  or  rubber  catheter;  (6)  sterile  sponges;  (c)  a  basin  of  sterile 
water;  (d)  a  basin  of  1-1000  bichloride  solution;  (e)  a  receptacle 
for  the  urine;  and  (/)  a  pair  of  rubber  gloves  or  four  finger  cots 
for  the  nurse.  All  materials  should  be  perfectly  sterile.  A  small 
jar  of  sterile  glycerine,  or  other  lubricant,  is  sometimes  added 
to  the  above  outfit.  The  preparation  of  the  patient  consists  in 
the  careful  cleansing  of  the  vulva  and  the  area  around  the  urinary 
meatus,  first  with  sterile  water  and  then  with  bichloride  solution. 
The  preparation  of  the  nurse  consists  in  careful  scrubbing  of  the 
hands,  as  for  operative  work,  and  the  additional  use  of  sterile  rubber 
gloves  or  of  sterile  rubber  finger  cots  upon  the  thumb  and  index 
finger  of  each  hand.  After  the  careful  preparation  of  patient  and 
nurse,  the  labia  are  well  separated  with  the  thumb  and  forefinger 
of  the  left  hand  and  the  catheter  introduced  with  the  correspond- 
ing fingers  of  the  other  hand.  After  the  withdrawal  of  the 
catheter,  the  parts  should  again  be  sponged  off  with  bichloride. 


154  MINOR  TECHNIC  IN  SURGICAL  NURSING 

The  variations  that  are  resorted  to  for  the  purposes  of  render- 
ing this  proceeding  less  exacting  are  generally  with  respect  to  the 
preparation  of  the  nurse,  the  preparation  of  the  patient  remaining 
the  same.  In  such  cases,  the  scrub  is  sometimes  omitted, — con- 
fidence being  placed  in  the  protective  power  of  the  gloves.  In 
others,  finger  cots  are  used,  without  the  scrub.  In  others,  pieces 
of  sterile  or  bichloride  soake'd  gauze  are  substituted  for  either 
gloves  or  cots,  and  the  scrub  is,  of  course,  again  omitted.  Yet 
another  evasion  of  the  most  careful  technic  is  the  use  of  a  steril- 
ized forceps  to  grasp  and  insert  the  catheter,  this  instrument 
taking  the  place  of  both  scrub  and  gloves.  These  methods  are 
mentioned  because  they  are  frequently  observed  in  hospitals 
where  the  authorities  would  feel  insulted  if  any  question  were 
raised  regarding  the  perfection  of  their  aseptic  technic,  and  with 
the  view  of  condemning,  not  condoning.  It  is  true  that  our 
methods  are  more  or  less  dependent  upon  our  supplies  and 
surroundings,  but  the  duty  is  ours  to  see  that  our  methods  are 
either  the  best  that  we  know  or  the  best  that  we  can  attain  under 
existing  conditions.  Unless  we  attain  this  requirement  of  every 
conscientious  physician  or  nurse,  we  must  consider  ourselves 
directly  responsible  for  any  unsavory  results  of  our  work. 

3.  Bladder  Irrigation. — Bladder  irrigation,  by  the  nurse,  is 
for  the  purpose  of  removing  infectious  and  cast-off  material  from 
the  bladder  and  for  applying  remedial  agents  to  its  lining  mem- 
brane. The  apparatus  for  its  proper  performance  consists  of 
soap  and  water  and  a  1-10,000  sol.  of  bichloride  of  mercury  for 
cleansing  the  vulva  and  meatus;  a  sterile  glass  funnel  with  tube 
attached;  a  rubber  catheter  and  glass  joint  for  connecting  it  with 
the  tube  and  funnel;  a  receptacle  for  receiving  the  return  flow 
from  the  irrigation,  and  a  pitcher  of  the  chosen  solution.  The 
solution  used  may  be  of  any  one  of  a  number,  ranging  from  sterile 
water,  through  physiological  salt  solution  and  boracic  acid  solu- 
tion, up  to  the  stronger  antiseptics, — as  potassium  permanganate, 
silver  nitrate  and  protargol.  The  solution  should  be  warm,  but 
not  hot, — a  temperature  of  between  100°  and  105°  F.  is  best. 
The  entire  vulva  should  be  carefully  cleansed, — first  with 
soap  and  water,  and  then  with  a  solution  of  bichloride  of  mer- 
cury. The  nurse's  hands  should  be  scrubbed  and  then  im- 
mersed in  a  solution  of  bichloride.  The  funnel,  tube,  joint 
and  catheter,  as  well  as  the  pitcher  containing  the  solution,  should 
be  sterilized  by  boiling  and  the  solution  prepared  from  sterile 


REMEDIAL  MEASURES  155 

water.  The  catheter  is  then  inserted  and  such  urine  as  may  be 
in  the  bladder  drawn  off.  The  joint  between  the  tube  and  cathe- 
ter is  now  connected,  care  being  taken  to  see  that  the  tube  is 
filled  with  solution  so  as  to  prevent  the  introduction  of  air  into 
the  bladder.  The  funnel  is  filled  with  solution  (being  held  at  or 
below  level  of  bladder)  and  the  solution  run  into  the  bladder  by 
raising  the  funnel  to  a  height  of  several  inches  or  a  foot  above 
the  bladder.  This  process  is  repeated  several  times,  until  the 
patient  complains  of  a  sensation  of  fulness,  when  the  process  is 
reversed, — the  funnel  being  lowered  until  it  is  filled  by  the  return 
flow,  which  is  emptied  into  the  provided  receptacle,  and  the 
process  repeated  until  there  is  but  one  funnel-ful  left  in  the 
bladder.  The  object  of  leaving  some  of  the  solution  in  the 
bladder  is  to  prevent  the  already  inflamed  and  tender  bladder 
walls  from  collapsing  and  coming  in  contact  with  the  catheter. 
This  precaution  requires  the  nurse  to  keep  accurate  count  of 
the  amount  of  solution  that  has  been  introduced, — an  easy  matter 
if  the  number  of  times  that  the  funnel  is  filled  be  remembered. 
This  filling  and  emptying  of  the  bladder  is  repeated  a  number  of 
times, — the  number  depending  upon  the  condition  present  and 
the  result  desired. 

4.  Vaginal  Douche. — The  vaginal  treatments  with  which  the 
nurse  is  most  immediately  concerned  are  the  various  solutions 
used  for  medicated  douches.  The  effects  of  vaginal  douches  are 
remedial  in  three  ways:  by  the  action  of  heat  and  cold;  by  their 
mere  mechanical  cleansing  effect;  and  by  the  application  of  cura- 
tive solutions  to  the  parts.  Two  or  more  of  these  objects  may 
be  combined  by  the  giving  of  a  warm  douche  of  some  antiseptic 
solution  for  the  multiple  purpose  of  obtaining  the  combined 
benefits  of  heat,  cleansing  and  antisepsis. 

Technic. — The  necessary  articles  are  a  glass  or  enamel  douche 
can  or  rubber  douche  bag,  a  rubber  tube  and  a  glass  vaginal 
douche  nozzle  for  the  administration  of  the  douche.  In  addition, 
there  should  be  the  douche  pan  for  the  patient  and  the  solutions 
and  sponges  for  cleansing  the  external  genitalia.  The  can,  tube 
and  tip  should  be  sterilized  by  boiling.  The  solution  should  be 
prepared  from  sterile  water.  The  preparation  of  the  external 
genitalia  should  be  as  that  for  catheterization.  And  the  prepara- 
tion of  the  nurse  should  be  the  same  as  for  any  other  aseptic 
procedure.  It  is  true  that,  in  some  cases,  the  strictest  technic 
may  seem  somewhat  out  of  place,  but  the  habitual  slighting  of  the 


156  MINOR  TECHNIC  IN  SURGICAL  NURSING 

proper  technic  in  s<yne  of  the  less  important  cases  will  invariably 
lead  up  to  a  corresponding  carelessness  in  the  occasional  case 
where  the  error  will  involve  vital  responsibility.  The  douche  tip 
having  been  introduced  under  aseptic  precautions,  the  can  is 
raised  until  there  is  a  free  flow  without  excessive  speed  or  force. 
The  object  of  the  douche  is  never  to  run  a  stream  of  solution  as 
rapidly  and  forcefully  as  possible  over  the  mucous  surface  of  the 
vagina,  but  to  bathe  with  a  cleansing  or  curative  application — 
and  this  fact  should  never  be  lost  sight  of  in  the  demands  of 
hospital  work  upon  the  time  and  efforts. 

5.  Changing  of  Perineal  Dressings  After  Vaginal  or  Perineal 
Operation. — The  duty  of  keeping  the  perineal  dressings  fresh 
after  a  minor  operation  is  generally,  and  indeed  necessarily,  left 
to  the  nurse.  As  it  is  necessary  for  the  nurse  to  remove  these 
dressings  every  time  that  -the  patient  desires  to  urinate  or  to 
have  an  evacuation  of  the  bowels,  and  to  carefully  cleanse  the 
parts  with  an  antiseptic  solution  before  reapplying  the  dressings, 
it  is  only  natural  that  the  entire  responsibility  of  caring  for  these 
dressings  should  be  assigned  to  her.  She  should  see,  as  above 
indicated,  that  the  parts  are  carefully  cleansed  after  passage  of 
urinary  or  fecal  matter.  She  should  also  see  that  the  dressings 
are  maintained  in  a  fresh  condition  at  all  times  and  that  they 
be  not  permitted  to  become  so  disarranged  that  the  operative 
wound  is  exposed  to  infection  or  the  patient's  bedclothing  to 
soiling  with  the  discharges.  The  dressings  are  usually  of  the 
simplest  character,  consisting  of  specially  constructed  vulvar  pads, 
sterile  gauze  fluffs,  or  any  of  the  other  usual  forms  of  sterile 
dressings,  kept  in  position  by  a  T-binder. 

III.  ASEPTIC  WARD  MEASURES,  IN  WHICH  THE  NURSE  PRE- 
PARES AND  ASSISTS 

In  taking  up  this  branch  of  gynaecological  nursing,  we  shall 
endeavor  to  give  the  nurse  an  idea  of  just  what  will  be  required 
of  her  in  the  preparation  for  some  of  the  more  usual  and  important 
of  the  ward  measures  in  which  she  participates  as  the  assistant 
of  the  attending  or  resident  physician.  It  is,  of  course,  impossible 
to  say  in  positive  terms  that  there  are  certain  things  and  none 
other  that  will  be  expected  of  her,  as  the  custom  must  vary  in 
different  institutions  and  under  different  surgeons.  The  endeavor, 
therefore,  will  be  to  give  a  general  outline  that  will  enable  the 
nurse  to  see  what  will  be  expected  of  her  in  the  ordinary  course 


REMEDIAL  MEASURES  157 

of  events  and  the  instruments  that  are  always  necessary  and  gen- 
erally sufficient  for  the  end  in  view. 

1 .  The  Dressing  Room. — A  separate  room  for  the  dressing  of 
wounds  is  a  desirable  but  not  essential  adjunct  to  the  ward. 
There  may  be  a  separate  room  for  each  ward,  or  one  well-equipped 
room  or  suite  of  rooms  may  serve  for  several  or  even  for  all  of 
the  wards  of  the  hospital.    In  the  latter  case  a  number  of  nurses 
will  be  assigned  to  special  duty  in  the  dressing  room  during 
certain  hours  of  the  day,  usually  in  the  morning.     Clean  cases 
are  better  dressed  apart  from  septic  ones,  although  with  proper 
precautions  the  danger  of  a  wound's  becoming  infected  at  a 
dressing  is  small.    The  equipment  of  the  dressing  room  will  be 
much  like  that  of  the  operating  room,  but  on  a  smaller  scale. 

2.  The  Dressing  Cart. — There  are  always  cases  in  the  open 
wards  that  cannot  be  safely  or  conveniently  moved  to  the  dressing 
room,  and  private  patients  are  usually  dressed  in  their  own  rooms. 
For  these  cases  some  kind  of  a  vehicle  on  wheels  must  be  used  to 
convey  the  instruments  and  materials  required  for  a  wound 
dressing  to  the  bedside. 

Many  forms  of  ward  dressings  carriages  or  carts  are  supplied 
by  the  manufacturers.  There  is  little  choice  between  them.  The 
carriage  should  be  on  large  rubber-tired  wheels  and  should  have 
plenty  of  shelf  room  for  the  materials  to  be  conveyed.  An  irri- 
gating stand  attached  to  the  carriage  is  not  a  specially  desirable 
addition.  The  carriage  may  be  equipped  either  for  a  single 
dressing  or  for  a  number  of  dressings  to  be  done  in  succession, 
and  the  arrangement  of  supplies  will  be  somewhat  different  for 
these  two  purposes.  Where  several  dressings  are  to  be  done  one 
or  two  drums  filled  with  dressing  materials  and  sponges  in  sterile 
packages  sufficient  for  all  the  cases  will  be  provided,  and  enough 
dressing  instruments  to  supply  a  fresh  set  for  each  individual 
case  may  be  sterilized  in  bulk.  An  empty  tray  for  soiled  instru- 
ments, and  basins  or,  better,  paper  bags  for  the  soiled  dressings 
will  be  needed,  together  with  an  abundant  supply  of  bandages, 
adhesive  straps  and  binders.  A  number  of  prepared  wick  drains, 
iodoform  gauze  in  strips,  and  also  uterine  and  vaginal  gauze 
should  be  included  in  the  equipment.  Adhesive  straps  with 
tapes  attached  may  be  occasionally  called  for  and  several  sets 
should  be  provided.  Certain  stock  supplies  should  be  always  on 
the  carriage;  benzine  for  loosening  adhesive  plaster;  alcohol; 
tincture  of  iodine  with  alcohol  (equal  parts);  a  flask  of  sterile 


158  MINOR  TECHNIC  IN  SURGICAL  NURSING 

normal  salt  solution;  peroxide  of  hydrogen;  balsam  of  Peru;  sterile 
vaseline;  oxide  of  zinc  ointment ;  boric  acid  ointment;  dichloramin- 
T,  pencils  of  fused  silver  nitrate  (lunar  caustic)  and  nitrate  of 
silver  in  solution ;  scarlet  red ;  talcum  powder  and  special  formulae 
of  dusting  powders;  and  one  or  two  basins  containing  bichloride 
(1  to  3000)  or  other  antiseptic  solution. 

3.  Dressing  the  Abdominal  Wound. — As  the  first  step  in  the 
dressing  of  an  abdominal  wound  is  the  removal  of  the  old  dressing, 
and  as  the  old  dressing  is  generally  held  in  place  by  adhesive 
straps,  the  first  necessity  is  something  for  the  removal  of  the 
adhesive  plaster.     Therefore,  the  first  accompaniment  of  the 
dressing  tray  (or  carriage)  is  a  small  bottle  of  benzine.      This 
should  be  accompanied  by  sponges  for  its  application.    The  next 
article  is  a  pus  basin,  or  other  receptacle,  for  the  old  dressings 
and  the  sponges  to  be  used  in  the  present  dressing.     Next  in 
order  come  the  sterile  instruments  for  the  proper  performance 
of  the  dressing  and  the  removal  of  stitches.    These  are:  a  basin 
with  bichloride  solution;  sterile  sponges;  two  dressings  forceps; 
one  thumb  forceps;  one  scissors.    This  list  completes  the  instru- 
ments necessary  for  the  ordinary  dressings,  but  these  are  usually 
supplemented  by  the  addition  of  a  probe.    As  a  large  part  of  the 
importance  of  the  dressing  should  be  the  welfare  and  comfort 
of  the  patient,  the  next  step  should  consist  in  carefully  going 
over  the  entire  area  that  has  been  covered  by  the  old  dressing, 
with  alcohol.    A  bottle  of  this  medicament  should,  therefore,  be 
found  on  every  dressing  carriage.    Finally  should  come  the  sterile 
dressings  and  the  adhesive  plaster  for  fastening  them  in  place. 
If  an  abdominal  binder  is  used,  a  fresh  one  should  be  at  hand 
for  use  at  the  completion  of  the  dressing.    As  supplements,  in 
the  occasional  case  where  slight  infection  or  granulation  is  found 
at  the  first  dressing,  it  is  well  to  add  a  small  bottle  of  balsam  of 
Peru  and  a  stick  of  silver  nitrate  to  each  dressing  tray. 

4.  Hypodermoclysis. — For    the    subcutaneous    injection    of 
physiological  salt  solution,  the  materials  required  are  those  for 
cleansing  the  field  of  injection,  for  performing  the  operation  and 
for  dressing  the  wound.    The  hypodermoclysis  tray  should,  there- 
fore, contain  alcohol,  bichloride  solution  and  sterile  sponges  for 
cleansing  the  skin;  sterile  apparatus  consisting  of  can,   tube, 
needles  and  thermometer;  hot  and  cold  sterile  physiological  salt 
solution,  so  that  it  may  be  prepared  at  a  temperature  of  about 
115°F.  at  the  time  of  injection;  and  a  small  sterile  gauze  dressing 


REMEDIAL  MEASURES  159 

with  adhesive  plaster  for  fastening  it  in  place  over  the  needle 
wound.  It  is  desirable,  although  not  necessary,  that  the  salt 
solution  container  be  graduated  in  ounces  or  cubic  centimetres 
so  that  the  exact  amount  of  the  solution  used  may  be  recorded. 

5.  Intravenous  Infusion  of  Physiological  Salt  Solution. — The 
tray  should  contain  the  same  articles  as  for  hypodermoclysis, 
with  certain  differences  and  additions.    All  articles  are  the  same 
with  the  exception  of  the  needles,  a  special  blunt-pointed  needle 
being  used  for  intravenous  infusion.    In  addition  to  these  articles, 
there  should  be  a  sterile  hypodermic  syringe  and  needle  and 
cocaine  solution  for  local  anaesthesia.     There  should  also  be 
included  a  dissecting  set  consisting  of  knife,  dissecting  forceps, 
scissors,  two  sterile  haemostatic  forceps,  some  sterile  No.  2  catgut 
and  two  small  cutting  needles — or  fine  silk  and  straight  round 
needles  for  skin  suture. 

6.  Uterine  or  Vaginal  Packing. — The  first  step  in  packing 
either  the  vagina  or  the  uterus  consists  in  properly  cleansing  the 
vulva.     For  this  purpose  bichloride  solution  and  sponges  are 
needed.    As  it  may  be  desirable  to  give  a  hot  douche,  either  for 
cleansing  purposes  or  as  a  preliminary  to  the  packing,  a  sterile 
douche  outfit  should  be  at  hand.     The  packing  outfit  proper 
should  contain:    one  bivalve  vaginal  speculum;  one  volsellum 
forceps;  one  uterine  dressing  forceps;  one  scissors;  and  sterile 
packing  gauze,  five  to  ten  yards.     In  case  the  vagina  alone  is 
packed,  the  volsellum  will  not  be  necessary.     In  addition  to 
the  articles  already  enumerated,  one  pair  of  sterile  rubber  gloves 
should  be  prepared  for  the  physician,  in  case  he  wants  to  use  them. 


CHAPTER  XI 
THE  CARREL-DAKIN  TECHNIC 

1.  Infected  Wounds  in  the  World  War. — Among  the  many 
lessons  which  surgeons  have  learned  from  the  experiences  of  the 
world  war  perhaps  none  are  of  more  value  than  those  concerned 
with  the  treatment  of  infected  wounds.  The  success  of  the 
aseptic  technic  as  applied  to  operative  wounds  had  left  us  blind 
to  the  importance  of  the  problem  presented  by  cases  of  severe 
wound  infection,  which  were  relatively  rare  in  times  of  peace. 
In  these  cases  surgeons  were  content,  when  adequate  drainage 
had  been  secured,  to  rely  for  the  rest  on  various  measures  of  more 
or  less  doubtful  value.  No  exact  scientific  studies  had  ever 
been  made  for  the  solution  of  this  problem. 

The  great  battles  of  the  world  war  soon  brought  a  rude  awak- 
ening. The  rich  moist  soils  of  France  and  Belgium,  densely 
populated  for  centuries,  were  saturated  with  bacteria  derived 
from  human  arid  animal  sources,  and  in  the  trenches  soil  contam- 
ination of  wounds  was  unavoidable.  The  hospitals  behind  the 
battle  line  were  filled  with  thousands  of  victims  of  shattering 
shell  wounds,  all  of  them  infected,  many  with  a  severity  and 
extent  of  septic  disease  rarely  seen  in  peaceful  times.  It  was  as 
if  we  had,  all  at  once,  been  transported  back  to  the  time  before 
Lister,  and  surgeons  suddenly  realized  that  while  they  knew 
how  to  prevent  infection  in  operative  wounds,  they  did  not 
know  how  to  cure  infection  once  it  was  well  established,  or 
even  how  to  prevent  it  in  extensive  lacerated  wounds  contami- 
nated by  the  bacteria-laden  soil  of  the  trenches  and  in  men 
devitalized  by  unendurable  exposure  and  the  hideous  exhaustion 
of  the  battlefield. 

The  demonstration  that  an  infected  wound  can  be  rendered 
practically  sterile  and  can  then  be  closed  and  made  to  heal 
primarily,  like  a  clean  operative  wound,  was  the  work  of  Dr. 
Alexis  Carrel ,  whose  researches  were  founded  upon  the  experi- 
ments of  Dr.  Henry  D.  Dakin,  made  in  the  laboratories  of  the 
Rockefeller  Foundation  established  at  Compiegne.  As  the  result 
of  this  research,  a  method  for  the  treatment  of  infected  and  sup- 
160 


THE  CARREL-DAKIN  TECHNIC  161 

purating  wounds  was  developed,  whereby  wounds  which  would 
ordinarily  have  suppurated  for  many  months  were,  in  the  large 
majority  of  cases,  completely  healed  in  from  two  to  four  weeks. 
The  saving  of  many  lives,  the  relief  of  suffering,  the  prevention 
of  complications,  the  shortening  of  time  in  the  hospital,  and 
great  improvement  in  end  results,  due  to  the  avoidance  of 
the  disastrous  effects  of  long  continued  suppuration;  these 
were  some  of  the  results  of  the  new  method.  This  achievement 
constitutes  a  new  and  brilliant  chapter  in  the  history  of  the 
conquest  of  wound  infection  which  is  briefly  outlined  at  the 
beginning  of  this  book. 

2.  The  Conditions  of  the  Problem. — It  had  long  been  believed 
by  many  surgeons  that  the  sterilization  of  a  septic  wound  was 
impossible  of  accomplishment  because  any  chemical  capable  of 
destroying  bacteria  would  also  kill  the  living  cells  of  the  wounded 
tissues.    This  view  failed  to  take  into  account  the  fact  that  there 
is  a  difference  in  resistance  between  living  tissues  provided  with  a 
circulation  and  isolated  cells  whether  of  the  tissue  or  bacteria. 
The  margin  is  a  narrow  one,  but  it  has  been  proved  to  be  sufficient. 
It  was  necessary  therefore  to  determine  by  experiment  the  best 
antiseptic  for  the  purpose  and  the  exact  concentration  which 
would  have  the  effect  of  destroying  bacteria  without  injuring  or 
irritating  the  living  tissues  of  the  human  body.    It  was  also  neces- 
sary to  determine  the  length  of.  time  this  antiseptic  must  be 
applied  in  order  to  bring  a  septic  wound  to  an  aseptic  condition, 
and  to  develop  an  efficient  technic  for  its  application. 

3.  Dakin's   Solution. — In   the  experiments   carried   out   by 
Dr.  Dakin  a  large  number  of  substances  were  examined  with 
respect  to  their  bactericidal  power  and  their  irritating  action 
upon  normal  tissues.     The  substance  finally  selected  was  the 
hypochlorite  of  soda  in  neutral  solution  of  one-half  of  one  per 
cent,  strength. 

The  hypochlorite  of  soda  is  a  very  powerful  disinfectant  but 
the  solution  made  in  the  ordinary  way  (Labarraque's  Solution) 
cannot  be  used  because  it  contains  free  alkali  in  the  form  of 
caustic  soda  in  varying  quantity  and  is  therefore  very  irritating. 
The  preparation  of  a  solution  free  from  this  irritating  content 
was  not  a  simple  matter,  since  dilution  with  waler,  and  also  con- 
tact with  organic  matter,  causes  an  increase  of  free  alkali  by 
dissociation  of  the  hypochlorite.  Simply  to  neutralize  the  alkali 
therefore  would  not  suffice.  It  was  necessarj'  to  have  what  is 
11 


162  MINOR  TECHNIC  IN  SURGICAL  NURSING 

known  as  a  " balanced"  solution,  in  which  small  additions  of 
alkali  or  acid  are  automatically  taken  up,  the  result  being  merely 
a  change  in  the  relative  proportions  of  certain  salts  contained 
in  the  solution,  while  its  neutral  reaction  is  unaffected.  This 
difficulty  was  solved  by  Dakin  in  the  solution  which  bears  his 
name.  There  are  a  number  of  ways  of  preparing  the  solu- 
tion. The  simplest  is  that  originally  advised  by  Dakin,  which 
is  as  follows: 

In  ten  litres  of  ordinary  tap  water  dissolve  140  grammes  of 
anhydrous  carbonate  of  soda  (or  400  grammes  of  the  crystallized 
salt,  commonly  known  as  washing  soda).  Add  200  grammes  of 
chloride  of  lime  (of  at  least  23  per  cent,  strength  in  "available 
chlorine").  The  mixture  is  to  be  thoroughly  shaken.  After  allow- 
ing it  to  stand  half  an  hour,  siphon  off  the  clear  fluid  and  filter  it 
through  cotton.  Add  40  grammes  of  boric  acid  and  the  resulting 
solution  is  ready  for  use.  It  is  usual  to  color  it  to  a  rose  tint  by  the 
addition  of  1  c.c.  per  litre  of  a  0.5  per  cent,  solution  of  permanga- 
nate of  potash.  The  solution  should  be  prepared  by  some  one  with 
sufficient  practical  knowledge  of  the  technic  of  chemical  manipu- 
lation to  test,  by  titration,  the  exact  strength  of  the  hypochlorite 
from  time  to  time.  The  solution  when  used  should  contain  not 
more  than  0.5  per  cent.,  nor  less  than  0.45  per  cent,  of  hypochlorite 
of  soda,  so  narrow  is  the  margin  between  the  concentration  of  the 
hypochlorite  of  soda  which  suffices  to  kill  bacteria,  and  that  con- 
centration at  which  irritation  of  the  living  tissues  will  begin  to 
appear.  The  solution  should  be  kept  in  a  cool  dark  place  in  an 
amber  bottle  and  be  renewed  every  10  to  15  days.  Some  surgeons 
prefer  to  have  it  made  fresh  every  day. 

4.  Outline  of  the  Carrel  Technic. — The  treatment  of  an 
infected  wound  by  the  Carrel  method  consists  of  three  stages. 
(1)  The  mechanical  cleaning  of  the  wound  by  a  surgical  operation, 
consisting  of  free  openings,  the  removal  of  foreign  bodies  and  dead 
tissue,  etc.  (2)  The  chemical  sterilization  of  the  wound  by  Dakin's 
solution.  (3)  The  final  closure  of  the  sterilized  wound  by  opera- 
tive means.  When  severe  inflammation  is  already  present  a 
preliminary  Dakinization  precedes  the  first  stage.  The  first  and 
third  of  these  stages  need  only  be  referred  to  here  since  the  duties 
of  the  nurse  in  connection  with  them  are  such  as  she  has  already 
become  familiar  with  in  her  training  in  the  operating  room. 

The  proper  carrying  out  of  the  second  stage,  that  of  the  appli- 
cation of  Dakin's  solution  in  the  wound  and  the  routine  of  daily 


THE  CARREL-DAKIN  TECHNIC  163 

dressings,  calls  for  the  most  perfect  teamwork  on  the  part  of  the 
nurse  and  the  surgeon.  It  is  an  exacting  technic,  and  it  is  the 
purpose  of  this  chapter  to  make  clear  the  particular  duties  of  the 
nurse  in  this  connection  and  the  reason  for  them. 

Obviously  to  secure  sterilization  of  a  wound  the  solution 
employed  must  be  brought  into  contact  with  every  part  of  the 
wounded  surface.  This  is  accomplished  by  means  of  rubber 
tubes  of  small  calibre  (4  mm.)  closed  at  one  end  and  provided 
with  numerous  small  openings  extending  some  distance  from  the 
closed  end.  These  "  instillation"  tubes  are  applied  directly  on 
the  surface  of  the  wound,  or  within  its  hidden  pockets,  in  such  a 
manner  that  the  flow  of  solution  will  be  evenly  distributed 
over  every  part  of  the  wound.  They  are  fixed  in  position  by  pads 
of  gauze  wet  with  Dakin's  solution.  The  open  ends  of  these  tubes 
emerge  from  the  dressing  and  are  attached  to  a  glass  "distribut- 
ing" tube  having  the  requisite  number  of  branches,  and  fastened 
to  the  dressings  by  safety  pins.  The  glass  distributing  tube  is 
connected  by  means  of  a  rubber  tube  (supply  tube)  of  larger 
calibre  (7  mm.)  with  the  opening  in  the  bottom  of  an  irrigating 
bottle  suspended  about  three  feet  above  the  level  of  the  wound. 
The  supply  tube  is  ordinarily  kept  closed  by  a  pinchcock  which 
is  opened  for  a  few  seconds  every  two  hours,  day  and  night,  to 
allow  the  solution  to  flood  the  wound  surface.  The  skin  about 
the  wound  is  protected  from  possible  irritation  by  strips  of  vase- 
lined  gauze.  The  final  dressing  is  very  simple,  consisting  of  a 
large  pad,  made  with  cotton  between  gauze  layers,  which  is 
wrapped  about  the  limb  and  fastened  with  safety  pins.  No 
bandages  are  used.  " Smears"  and  cultures  are  taken  at  proper 
intervals  from  the  wound  surface  to  determine  by  examination 
when  the  bacteria  have  disappeared.  The  limb  may  be  immobi- 
lized by  suitable  apparatus.  A  "Balkan  frame"  (Fig.  70)  makes 
it  possible,  in  fracture  cases,  to  suspend  the  limb  and  apply 
extension,  by  means  of  weights  and  pulleys,  with  a  minimum 
restriction  to  the  movements  of  the  patient.  When  continuous 
"instead  of  intermittent  irrigation  is  desired,  only  one  tube  with  a 
single  lateral  opening  is  placed  on  the  wound,  and  a  drop  counter 
is  introduced  in  the  course  of  the  supply  tube.  The  drop  counter 
must  never  be  installed  when  more  than  one  instillation  tube 
is  used. 

5.  Effects  of  Dakin's  Solution. — Dakin's  solution  kills  bacteria, 
destroys  bacterial  toxins  and  dissolves  necrotic  tissue.  It  is  not 


164  MINOR  TECHNIC  IN  SURGICAL  NURSING 

toxic  as  applied  to  a  wound  and  does  not  irritate  the  wound  or 
retard  the  healing  process.  It  is  slightly  irritating  to  the  skin 
which  is  not  so  close  to  the  circulating  blood  as  the  wound  surface. 
It  cannot  be  used  with  safety  within  the  peritoneal  cavity. 
The  time  required  to  sterilize  an  infected  wound  is  3  to  15  days 
or  longer  in  suppurating  wounds  and  in  compound  fractures. 
The  pus  from  a  suppurating  wound  when  Dakinized  changes  its 
character.  It  becomes  viscid  and  semitransparent  and  floats  on 
water  instead  of  sinking  as  pus  does. 

6.  Preparation  of  Materials. — Tubing  from  which  instillation 
tubes  are  made  is  of  maroon  rubber,  internal  diameter  4  mm., 
thickness  of  walls  of  tube  1  mm.  All  Carrel  tubes  (except  empy- 
ema  tubes)  are  cut  in  30  cm.  lengths  (about  12  inches).  Using 
linen  thread,  number  25  or  30,  tie  the  end  of  each  tube  with  a 
secure  knot,  and  cut  end  of  tube  close  to  thread.  With  a  rule, 
graduated  in  centimetres,  mark  off  tube  with  a  lead  pencil,  making 
dots  1  cm.  apart,  the  first  dot  close  to  the  tied  end.  With  the 
special  Carrel-Dakin  punch  puncture  the  tube  at  the  dot  marks. 
Every  other  hole  must  be  at  right  angles  to  the  preceding  one. 
Dakin  tubes  are  numbered  according  to  the  number  of  holes 
punched.  Thus  No.  5  tube  is  perforated  for  a  distance  of  5  cm. 
from  the  end,  No.  20  for  20  cm.  Tubes  usually  used  are  Nos.  5, 
10,  15,  and  20.  Occasionally  No.  1  (with  open  end  and  a  single 
lateral  perforation)  is  called  for.  For  empyema  cases  instillation 
tubes  (No.  20)  are  40  cm.  long  and  provided  with  a  silver  wire, 
inside  the  tube  to  stiffen  them.  " Covered"  tubes  are  made  by 
making  a  cylindrical  wrapping  of  bath  toweling  extending  from 
end  of  tube  to  2  cm.  beyond  the  last  perforation.  The  toweling 
is  cut  to  fit  and  sewed  on  with  linen  thread,  all  cut  edges  turned 
in.  In  tying  off  these  tubes  leave  threads  long  and  tie  through 
toweling  to  prevent  slipping.  The  " supply"  tube  connection 
with  irrigating  bottle  is  7  mm.  internal  diameter  and  is  cut  in 
lengths  of  about  3  feet  9  inches. 

Vaseline  gauze  strips  are  prepared  for  protection  of  the  skin. 
Cut  a  three  and  a  half  inch  bandage  in  7-inch  lengths.  Make  an 
even  pile  and  place  in  a  suitable  receptacle  (a  small  tin  biscuit 
box  answers  well).  Melt  together  vaseline  91  parts,  paraffin 
6  parts,  resin  3  parts.  Pour  over  gauze  strips,  allow  to  soak  well 
and  pour  off  excess.  Cover  and  sterilize  in  autoclave. 

Carrel-Dakin  dressing  pads  are  made  with  two  layers  of  non- 
absorbent  cotton  and  one  layer  of  absorbent  cotton,  the  whole 


THE  CAREEL-DAKIN  TECHNIC 


165 


Fio.  74.— (1)  No.  5  Instillation  tube;    (2)  No.  5  covered  tube;    (3)  distributing  tube 

with  4  branches;  (4)  Gentile's  syringe;  (f>)  an  arrangement  of  tubes  and  dressings; 

(6)  chart  showing  rapid  sterilization  of  a  wound. 


166  MINOR  TECHNIC  IN  SURGICAL  NURSING 

folded  in  a  gauze  cover.    The  absorbent  side  goes  against  the 
wound.    The  sizes  are  as  follows: 

Number                                         Pad  Gauze 

A 5  by  5    inches  8  by  12  inches 

1 6  by  10  inches  12  by  29  inches 

2 9  by  13  inches  12  by  29  inches 

3 13  by  21  inches  24  by  30  inches 

4 18  by  30  inches  22  by  64  inches 

Pads  number  3  and  4  are  double  thickness. 

Small  cotton  sponges  and  small  gauze  pads  (3  by  4  inches) 
will  be  provided  in  quantity. 

7.  Articles  on  the  Dressing  Carriage. — (1)    Two    long   sterile 
clamps  for  the  nurse  to  use  in  handling  instruments,  etc.     (2) 
The  dressing  tray  will  contain — Scalpel,  scissors  (2  to  4),  clamps 
(30  for  a  full  ward),  grooved  director,  probes,  sponge  holders 
(4),  razor.    (3)  Glassware,  sterile,  Gentile's  syringe  (a  very  useful 
syringe,  10  c.c.  capacity,  having  a  rubber  bulb  instead  of  a  piston; 
it  fits  the  instillation  tubing;  there  should  be  one  for  each  patient). 
Distributing  glass  tubes,  with  two,  three  and  four  branches, 
irrigation  nozzles,  union  tubes,  small  for  Carrel  tubing,  large  for 
supply  tube,  straight  and  Y  pattern.    (4)  For  taking  "smears  and 
cultures."     Platinum  loop,  alcohol  lamp,  matches,  glass  slides, 
gummed  labels,  lead  pencil.    Culture  tubes  containing  bouillon. 
(5)  Solutions,  etc.,  in  suitable  containers.     Dakin's  solution  (in 
5  litre  amber  glass  bottle  and  in  jar  on  carriage),  neutral  liquid 
soap  (page  178),  alcohol,  gasoline,  tincture  of  iodine,  sterile  water 
(hot),  zinc  oxide  ointment.    (6)  Dressings,  etc.,  sterile,  large  towels, 
small  towels,  gloves,  cotton  sponges,  small  gauze  tampons,  large 
dressing  pads  in  size  and  number  as  required,  vaseline  gauze  in  box, 
wooden  spatula.    (7)  Adhesive  strips,  gauze  bandages,  safety  pins, 
(8)  Instillation  tubes,  sterile  in  tray,  as  required  (12  open  and  8 
covered  of  each  size  for  a  full  ward) .    (9)  Basins.    Two  large  and 
two  small,  sterile.    One  basin  for  soiled  gloves,  one  for  soiled 
instruments,  one  for  soiled  tubes.    Two  pus  basins.    A  receptacle 
for  soiled    dressings.     The  ward  should   be  provided  with  an 
instrument  sterilizer,  preferably  electric. 

8.  Routine  Dressing  Rounds. — A  Carrel-Dakin  team  consists 
of  the  surgeon,  the  head  nurse,  an  assistant  nurse  and  an  orderly. 
In  a  full  ward  others  may  be  added  to  advantage.    The  surgeon 
and  the  head  nurse  scrub  up  and  are  gowned  and  gloved  as  for 
an  operation.    The  others  need  not  be  " sterile."    The  surgeon 


THE  CARREL-DAKIN  TECHNIC  167 

works  with  a  sterile  pair  of  forceps  in  each  hand.  He  does  not 
touch  wound  or  dressing  or  tubes.  He  may,  however,  on  occasion 
handle  unsterile  articles  with  his  gloved  hands  without  breaking 
the  technic.  The  clean  nurse  remains  sterile  throughout.  She 
stands  by  the  dressing  cart  and  hands  the  surgeon  what  he  re- 
quires from  time  to  time,  using  long  dressing  forceps  for  the  pur- 
pose. She  directs  the  team  and  sees  that  the  surgeon's  wants 
are  anticipated  as  far  as  possible. 

The  unscrubbed  nurse  shows  the  patient's  bacterial  chart 
(to  be  described  later)  to  the  surgeon,  she  then  unpins  and  folds 
back  the  dressing  pad,  while  the  surgeon  with  forceps  removes 
the  packs.  She  sterilizes  the  platinum  needle  in  the  alcohol  flame 
and  hands  it  to  the  surgeon  with  a  glass  slide.  After  the  surgeon 
has  made  a  " smear"  from  the  wound  surface  she  marks  the  slide 
with  date  and  number  of  bed.  The  surgeon  wipes  off  the  secre- 
tion from  the  wound  with  cotton  sponges  wet  with  Dakin's  solu- 
tion. He  washes  the  wound  with  neutral  soap  and  water,  and 
sometimes  with  gasoline  to  loosen  scales  and  crusts  about  the 
edges  of  the  wound.  He  irrigates  with  Dakin's  solution.  He 
tests  the  tubes  by  trying  each  with  a  syringeful  of  Dakin's  solu- 
tion. He  now  changes  instruments,  taking  fresh  forceps  which 
the  clean  nurse  hands  him.  He  places  fresh  tubes  in  the  wound 
and  fixes  them  with  compresses.  He  covers  the  surrounding  skin 
with  vaselined  gauze  strips  which  the  nurse  hands  him  one  by 
one,  picking  them  up  by  the  middle  with  a  pair  of  forceps.  The 
instillation  tubes  may  be  fixed  to  the  skin,  outside  the  edges  of 
the  vaselined  gauze,  by  narrow  strips  of  adhesive  plaster.  A 
fresh  dressing  pad  is  finally  applied  and  the  tubes  adjusted,  con- 
nected and  pinned. 

9.  Duties  of  the  Nurse  in  the  Intervals  Between  Dressings. — 
These  are  simple  but  most  important.  Instillation  is  performed 
every  two  hours,  day  and  night,  by  the  nurse  opening  the  pinch- 
cock  on  the  supply  tube  for  a  few  seconds  allowing  about  50  to 
10D  c.c.  to  flow  (250  to  1200  c.c.  in  24  hours).  The  dressing 
should  never  be  dripping  wet.  The  irrigation  bottle  should  never 
be  more  than  three  feet  above  the  wound.  If  the  patient  com- 
plains of  pain  at  the  instillation  lower  the  bottle  even  to  a  level 
of  one  foot  above  the  wound. 

Each  patient  will  have  a  chart  showing  the  wound's  progress 
toward  sterilization.  The  laboratory  will  report  daily  the  results 
of  examination  of  the  " smears,"  giving  the  average  number  of 


168  MINOR  TECHNIC  IN  SURGICAL  NURSING 

bacteria  seen  in  each  microscopic  field.  The  ordinary  respiration 
chart  with  changes  in  the  numbering  answers  well  for  this  pur- 
pose. On  it  the  nurse  will  chart  from  day  to  day  the  report 
from  the  laboratory,  which  will  indicate  from  J{0  to  70  bacteria 
per  field.  The  latter  number  will  be  replaced  with  the  sign  for 
infinity  ( °° )  meaning  too  many  to  be  worth  counting.  Reports 
on  cultures  will  be  written  on  the  chart. 

10.  Chloramines. — Chloramine-T  and  dichloramine-T  are 
organic  compounds,  containing  " active"  chlorine,  which  have 
a  useful  place  in  the  treatment  of  wound  infections  of  moderate 
severity.  Dakin's  solution,  because  of  its  unstable  character, 
disinfects  a  wound  vigorously  for  a  brief  time  and  then  loses  its 
potency,  hence  the  necessity  for  the  instillation  of  fresh  solution 
at  short  intervals.  The  chloramines  are  more  stable  than  the 
hypochlorite  of  soda  and  therefore  they  are  milder  and  more  pro- 
longed in  their  action.  They  are  not  toxic  and  not  irritating  and 
can  be  used  in  greater  concentration  then  the  hypochlorite. 
What  the  chloramines  lack  is  the  powerful  solvent  action  on  pus, 
blood  clots  and  necrotic  tissue  which  Dakin's  solution  has.  It  is 
for  this  reason  that  Dakin's  solution  is  immeasureably  superior  in 
the  disinfection  of  extensive,  badly  lacerated  and  freely  sup- 
purating wounds. 

Chloramine-T  is  water  soluble  and  may  be  used  in  1  per  cent, 
to  2  per  cent,  solution  in  wounds  with  the  Carrel  technic.  It 
keeps  well.  In  practice  a  2  per  cent,  stock  solution  may  be  diluted 
with  normal  salt  solution  as  required  for  special  purposes,  e.  g. 
1-500  for  injections  in  chronic  urethral  infections,  1-1000  for  the 
eye  and  a  weaker  solution  for  cystitis,  where  the  tolerance  is  even 
less.  Gauze  impregnated  with  chloramine-T  (5  per  cent,  by  weight) 
may  be  used  as  a  wound  packing.  The  gauze  should  not  be  wet 
before  use,  lest  the  chloramine  be  washed  out.  A  beautiful  pre- 
paration is  in  the  form  of  a  paste  or  cream  made  with  stearate  of 
soda  and  water  according  to  the  formula  of  Daufresne  (page  178). 

Dichloramine-T  is  not  soluble  in  water  and  the  preparation  of 
a  stable  solution  in  oil  requires  a  complex  manipulation.  It  is 
used  in  a  5  per  cent,  to  8  per  cent,  solution  in  a  specially  pre- 
pared solvent  known  as  "  chlorcosane. "  It  may  be  applied  to 
wounds  in  the  form  of  a  spray,  or  a  small  amount  (L  or  2  c.c. 
for  a  wound  of  moderate  extent)  may  be  introduced  with  a 
medicine  dropper.  It  need  not  be  renewed  more  than  once  in 
twenty-four  hours. 


CHAPTER  XII 

WEIGHTS,  MEASURES,   SOLUTIONS  AND  FORMULAE 
1.  WEIGHTS  AND  MEASURES 

ALTHOUGH  it  may  be  presupposed  that  the  nurses  who  are 
studying  the  surgical  and  gynaecological  part  of  their  course 
have  already  mastered  the  subject  of  weights  and  measures,  in 
its  various  applications,  yet  it  appears  wise  to  reconsider  it  in 
this  place,  particularly  in  connection  with  its  application  to  the 
preparation  of  solutions. 

There  are  two  systems  now  in  common  use  for  the  measuring 
of  distance,  weight  and  volume.  These  are  the  English  and  the 
metric  systems.  The  former  is  a  fairly  independent  and  unrelated 
series  of  tables,  each  with  its  distinct  unit,  which  is  increased  by 
arbitrary  multiples  to  obtain  the  next  higher  unit.  In  the  metric 
system,  however,  the  linear  unit  is  the  basis,  not  alone  for  the 
measure  of  distance,  but  also  of  weight  and  volume,  and  the 
graduation  of  succeeding  greater  units  is  based  upon  the  decimal 
system,  each  being  ten  times  greater  than  the  next  smaller.  Such 
a  system  is  obviously  more  scientific  and,  indeed,  more  simple 
than  the  English  system,  but  long  usage  has  made  the  latter  so 
much  a  part  of  our  customs  that  it  is  difficult  to  have  it  discarded, 
even  for  a  better. 

A.  Linear  Measure. — The  English  system  of  linear  measure 
is,  of  course,  familiar  to  all  and  is  given  here  merely  for  the  pur- 
pose of  comparison  with  the  metric  linear  measure. 

12  inches equal  1  foot 

3  feet equal  1  yard 

5l/i  yards equal  1  rod  (or  perch) 

40  rods equal  1  furlong 

8  furlongs equal  1  mile 

The  entire  metric  system,  as  already  stated,  is  based  upon  the 
linear  unit  (the  metre) ,  which  is  equal  to  one  ten-millionth  of  a 
quarter  meridian  of  the  earth,  or  about  39.37  English  inches. 
This  linear  unit  being  assumed,  those  of  successive  higher  order 
are  obtained  in  multiples  of  ten  (represented  by  Greek  prefixes) 
and  those  of  successive  lower  order  by  decimal  fractions  (repre- 
sented by  Latin  prefixes).  Thus  (where,  in  the  English  system, 

169 


170  MINOR  TECHNIC  IN  SURGICAL  NURSING 

we  obtain  the  successive  units  of  feet,  yards,  rods,  furlongs  and 
miles  by  multiplying  successively  by  twelve,  three,  five  and  a 
half,  forty  and,  finally,  eight)  we  have  the  metric  system,  in  the 
ascending  scale,  as  follows: 

10  metres .  .  .  equal       1  decametre  (Dm.) 

100  metres .  .  .  equal     10  decametres .  .  .  equal     1  hectometre  (Hm.) 
1000  metres.  .  .equal  100  decametres.  .  .equal  10  hectometres.  .  .equal  1  kilometre  (Km.) 

To  obtain  smaller  units  than  the  metre  (which,  being  some- 
what greater  than  the  English  yard,  is  too  large  a  unit  for  fine 
measurements),  we  have  recourse  to  the  descending  scale  of  deci- 
mals, with  the  Latin  instead  of  the  Greek  prefixes,  as  follows: 

.1  metre  (M.)  .  .equals     1  decimetre  (dm.) 

.01  metre equals     .1  decimetre,  .equals    1  centimetre  (cm.) 

.001  metre equals  .01  decimetre,  .equals  .1  centimetre,  .equals  1  millimetre  (mm.) 

To  somewhat  reverse  the  above  process,  we  have: 

1000  millimetres equal  100  centimetres equal  10  decimetres equal  1  metre 

As  the  centimetre  is  the  metric  unit  of  linear  measure  most 
commonly  used  in  hospital  work  and,  at  the  same  time,  the  one 
upon  which  the  units  of  weight  and  volume  are  based,  it  is  advis- 
able to  obtain  an  idea  of  its  value  jn  the  English  system.  As 
we  have  already  seen,  the  metre  equals  about  39.37  inches.  One 
centimetre,  being  one  one-hundredth  of  a  metre,  equals  one  one- 
hundredth  of  39.37  inches,  i.e.,  0.3937  inch.  This  is  approxi- 
mately four-tenths  of  an  inch. 

B.  Measure  of  Volume. — In  the  English  system  (apothe- 
caries') the  unit  of  volume  is  the  minim  (indicated  n^),  and  the 
names  of  the  successive  higher  units  are  equally  arbitrary  and 
unrelated,  as  are  the  multiples  by  which  they  are  obtained. 
Thus,  we  have: 

60  minims  (ir\lx) equal  1  fluidrachm  (£5  i) 

8  fluidrachms  (f  5  viii) equal  1  fluidounce  (f  5  i) 

16  fluidounces  (£S  xvi) equal  1  pint  (Oi) 

It  is  customary,  in  writing  these  terms,  to  employ  the  method 
parenthetically  indicated  above;  that  is,  to  use  the  symbol 
instead  of  writing  out  the  word  and  to  use  the  Roman  instead 
of  the  Arabic  numeral,  the  number  following  instead  of  preceding 
the  symbol. 

In  the  metric  system,  the  unit  of  volume  is  based  upon  the 
linear  unit.  It  is  termed  a  litre  and  is  equal  to  a  cubic  decimetre. 
A  decimetre  is  one-tenth  of  a  metre  (i.e.,  ten  centimetres).  A 
litre,  therefore,  equals  one  thousand  cubic  centimetres.  The 


WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULA       171 

larger  units  of  volume  are  obtained  identically  as  in  the  linear 
system,  by  the  use  of  Greek  prefixes  to  denote  successive  multiples 
of  ten  of  the  standard  unit  and  the  smaller  units  by  the  use  of 
Latin  prefixes  to  denote  successive  decimal  fractions.  Thus: 

10  litres equal       1  decalitre 

100  litres equal     10  decalitres equal  1     hectolitre  (HI.) 

1000  litres equal  100  decalitres equal  10  hectolitres equal  1  kilolitre  (Kl.) 

On  a  descending  scale,  we  have: 

1  litre  (L.) .  .equals  10  decilitres  (dl.) .  .equal  100  centilitres  (cl.) .  .equal  1000  millilitres  (ml.) 

To  this  brief  summary  may  be  added  that  the  cubic  centimetre, 
with  its  multiples  and  decimal  fractions,  is  usually  employed  as 
the  unit  of  volume  in  medical  work  and  is  equivalent  to  a  trifle 
over  nixvi.  The  litre  measures  somewhat  over  a  quart  (about 
1.05  quarts). 

C.  Measures  of  Weight. — In  the  English  system,  the  unit  of 
weight  is  the  grain  (abbreviated  gr.)  and  we  have  the  following 
table: 

20  grains  (gr.  xx) equal  1  scruple  (3  i) 

3  scruples  (3  iii) equal  1  drachm  (3  i) 

8  drachms  ( 5  yiii) equal  1  ounce  (Si) 

12  ounces  ( 3  xii) equal  1  pound  (Ibi) 

The  unit  of  weight  in  the  metric  system  is  the  gramme,  which 
represents  the  weight  of  one  cubic  centimetre  of  pure  water — 
thus,  again,  going  back  to  the  linear  system  for  its  unit.  And, 
again,  we  have  the  identical  system  of  construction  for  the 
table.  Thus: 

10  grammes  equal       1  decagramme  (Dg.) 

100  grammes  equal     10  decagrammes  equal     1  hectogramme  (Hg.) 
1000  grammes  equal  100  decagrammes  equal  10  hectogrammes  equal  1  kilogramme  (Kg.) 

and,  further, 

1  gramme  (Gm.) .  .  .equals  10  decigrammes  (dg.) .  .  .equal  100  centigrammes  (eg.) .  .  .equal 
1000  milligrammes  (ing.) 

The  gramme  is  equal  to  about  gr.  xv  in  the  apothecaries'  system. 
Although,  from  what  has  here  been  said,  we  may  gather  some 
idea  of  the  greater  simplicity  of  the  metric  over  the  English 
system  of  weights  and  measures,  yet  no  true  appreciation  of  the 
enormous  difference  can  exist  until  we  consider  that  only  one  of 
the  English  tables  of  weight  and  one  of  the  tables  of  volume  have 
been  considered  (the  apothecaries'  in  each  case).  When  we  realize 
that  there  are,  in  addition  to  these,  the  avoirdupois  and  troy 
systems  for  weights  and  the  imperial,  cubic  and  dry  measures 


172  MINOR  TECHNIC  IN  SURGICAL  NURSING 

for  volume,  then  alone  can  the  great  advantage  accruing  from  the 
general  adoption  of  such  a  system  as  the  metric  be  appreciated. 

Transposition  of  Tables. — After  the  somewhat  extended 
attention  given  to  prefatory  considerations,  we  shall  endeavor 
to  even  further  simplify  their  application.  The  tables  of  linear 
measure  will  be  disregarded  as  of  no  particular  interest  to  the 
nurse,  and  the  measures  of  volume  and  weight  will  be  considered 
as  possessed  of  only  one  Unit  each, — the  cubic  centimetre  and 
the  gramme.  We  have  already  stated  that  the  cubic  centimetre 
equals  about  16  minims  and  the  gramme  about  15  grains.  We 
have,  further,  stated  that  practically  all  prescriptions  employing 
the  metric  system  are  written  in  decimal  multiples  or  fractions 
of  these  units.  The  system  of  writing,  therefore,  is  identical  to 
that  employed  in  our  monetary  system, — the  unit  being  the 
cubic  centimetre  or  the  gramme  instead  of  the  dollar.  Thus,  it 
should  be  quite  as  simple  to  read  Gm.  3.25  as  $3.25, — one  repre- 
senting three  and  twenty-five  one-hundredths  dollars  and  the 
other  three  and  twenty-five  one-hundredths  grammes. 

The  transposition  from  one  system  to  the  other  should  be 
equally  simple.  Taking  the  above  example,  suppose  that  we 
wish  to  transpose  Gm.  3.25  to  its  equivalent  in  the  apothecaries' 
system  of  weights. 

We  know  .that  Gm.  1        equals  gr.  xv 

Therefore  Gm.  3.25  equals  15  X  3.25  equals  48.75  grains 

Thus,  Gm.  3.25  equal  gr.  48% 

The  reverse  process  is  equally  simple.  Suppose,  for  instance, 
that  we  wish  to  transpose  fgiiss  (2]/o)  from  the  apothecaries'  to 
the  metric  system. 

(1)  There  are  480  minims  in  an  ounce. 

(2)  Therefore  2>£  ounces  equal  2.5X  480  or  1200  minims. 

(3)  16  minims  equal  1  cubic  centimetre. 

(4)  Therefore  1200  divided  by  16  (i.e.,  75)  equals  the  number  of  cubic  centimetres  in  £3  iiss. 

(5)  Thus,  f3iiss=75  c.c. 

From  these  two  examples,  we  promptly  realize  the  simplicity 
of  the  application  of  the  following  general  rule:  To  change 
quantities  from  the  metric  to  the  apothecaries'  system,  multiply 
(if  liquid  and  expressed  in  cubic  centimetres)  by  16,  to  reduce  to 
minims,  and  (if  solid  and  expressed  in  grammes)  by  15  to  reduce 
to  grains.  To  change  from  the  apothecaries'  to  the  metric,  first 
reduce  to  grains  (or  minims)  and  then  divide  by  15  (if  solid)  to 
transpose  to  grammes,  or  by  16  (if  liquid)  to  transpose  to  cubic 
centimetres. 


WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULA       173 

II.  SOLUTIONS 

Since  such  a  large  part  of  the  surgical  nurse's  work  consists 
in  the  preparation  of  solutions  of  drugs,  it  seems  advisable  that 
something  more  than  passing  notice  should  be  devoted  to  this 
subject.  The  nurse  is  required  to  prepare  physiological  salt 
solution  for  dressings,  or  for  subcutaneous,  intravenous  or  rectal 
administration;  various  antiseptic  solutions  for  use  as  a  part  of 
the  aseptic  technic  or  for  wound  dressings;  solutions  for  enemata; 
solutions  for  vaginal  douches;  and  other  solutions  for  any  one, 
or  all,  of  the  various  fields  covered  by  surgical  nursing.  In  some 
instances,  the  amounts  of  the  various  constituents  will  be  given. 
In  others  only  the  percentage  strength  of  the  solution  will  be 
specified,  and,  possibly,  the  total  quantity  of  the  solution  to  be 
used.  It  is  in  the  latter  class  of  cases,  particularly,  that  the 
nurse  must  be  familiar  with  the  preparation  of  percentage 
solutions. 

The  method  of  preparation  of  these  solutions  naturally  divides 
itself  into  two  parts,  dependent  upon  which  system  of  weights 
and  measures  is  employed, — the  metric  or  the  apothecaries'. 
The  natural  tendency,  in  approaching  this  subject,  is  to  mention 
the  apothecaries'  system  only  to  condemn  its  use.  However,' 
the  realization  that  custom  has  made  the  apothecaries'  system 
the  routine  in  many  hospitals  makes  it  necessary  that  we  should 
give  it  due  consideration. 

To  make  an  aqueous  solution  (and  this  is  the  form  generally 
prepared  by  the  nurse)  of  any  drug,  it  is  first  necessary  to  decide 
how  much  of  the  drUg  must  be  used,  in  order  to  make  the  desired 
percentage  in  the  total  quantity.  The  simplest  method  of  accom- 
plishing this  is  by  resolving  the  volume  representing  the  total 
solution  into  its  smallest  units,  which  will  be  susceptible  of  treat- 
ment by  the  percentage  system.  For  example,  suppose  that  we 
are  required  to  make  up  two  gallons  of  a  one-half  per  cent,  solu- 
tion of  lysol.  This  looks  like  a  rather  imposing  task.  But,  by 
reducing  to  its  simplest  form,  we  have 

2  gallons  equal  8  quarts  equal  16  pints  equal  256  ounces  equal  122,880  minims 

1  per  cent,  of  122,880  is  1228.80 
Y2  of  this  is  614.40 

We,  therefore,  to  614  minims  of  lysol  add  enough  water  to  make 

2  gallons.    If  it  is  inconvenient  to  measure  614  minims,  we  may 
first  transpose  it  to  higher  units  by  the  process  of  division, 
remembering  that  60  minims  equal  1  drachm  and  that  8  drachms 


174  MINOR  TECHNIC  IN  SURGICAL  NURSING 

equal  1  ounce,  or  that  480  minims  equal  one  ounce.  Thus, 
dividing  614  minims  by  60,  we  find  the  equivalent  quantity  of 
3x  npciv,  and,  further  transposing  5x,  we  find  the  equivalent 
quantity  of  5i  5ii-  Therefore,  614  minims  equal  1  ounce,  two 
drachms,  14  minims. 

This  example,  which  shows  the  method  employed  to  find  the 
amount  of  a  liquid  drug  that  must  be  used  to  make  up  a  specified 
quantity  of  a  certain  percentage,  is  identical  with  that  used  for 
solids,  the  latter  being  measured  in  grains  instead  of  minims. 

In  the  use  of  the  metric  system,  practically  all  of  this  work 
is  unnecessary.  Suppose  that  we  take  the  same  example.  In 
the  first  place,  it  is  necessary  to  transpose  the  2  gallons  to  the 
metric  system.  The  quantity  being  so  large,  absolute  exactness 
may  be  to  some  extent  disregarded.  We  know  that  one  quart 
equals  approximately  one  litre.  Therefore,  2  gallons,  equalling 
8  quarts,  also  equal  8  litres.  We,  now,  have  the  problem  of 
making  8  litres  of  a  ^  per  cent,  lysol  solution. 

1  litre  equals  1000  cubic  centimetres 

8  litres  equal  8000  cubic  centimetres 

1  per  cent,  (or  one  one-hundredth)  of  8000  is  80.00 

Y*  of  80.00  is  40.00 

We,  therefore,  add  to  40  cubic  centimetres  of  lysol  sufficient 
water  to  make  8  litres.  The  only  inaccuracy  in  this  solution  is 
that,  by  transposing  to  the  metric  system,  we  have  made  up 
slightly  more  than  the  required  quantity  of  the  solution,  but  of 
exactly  the  required  percentage. 

III.  FORMULA 

In  every  hospital  there  are  in  general  use  a  number  of  stock 
solutions  or  preparations  for  various  purposes.  These  may  be 
in  the  form  of  tablets  of  a  given  strength,  from  which  the  diluted 
solutions  are  prepared,  or  they  may  be  in  the  form  of  solutions 
of  varying  degrees  of  concentration,  which  are  used  either  as 
prepared  or  after  considerable  dilution.  While  it  would,  of  course, 
be  quite  out  of  the  question  to  give  even  an  approximately  full 
list  of  these  preparations  in  this  place,  yet  a  few  of  the  more 
common  and,  possibly,  more  important  will  be  tabulated.  In 
addition,  there  will  be  included  some  formulae  which  may  not 
be  kept  prepared  but  which  appear  of  sufficient  importance  to 
warrant  their  presence  in  such  an  abbreviated  list. 


WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULA      175 

Formulae  for  local  anaesthesia: 

1.  Cocaine  and  adrenalin  (A): 

Cocaine  hydrochloride 0.03    gm. 

Adrenalin  chloride 0.003  gm. 

Sodium  chloride 0.18    gm. 

Distilled  water 30.00    c.c. 

This  makes  a  solution  of  cocaine  (1-1000)  and  adrenalin  (1-10,000) 
in  physiological  salt  solution. 

2.  Cocaine  and  adrenalin  (B) : 

Cocaine  hydrochloride 0.3      gm. 

Adrenalin  chloride 0.03    gm. 

Sodium  chloride 0.18    gm. 

Distilled  water 30.00    c.c. 

This  makes  a  solution  of  cocaine  (1-100)  and  adrenalin 

(1-1000)  in  physiological  salt  solution. 
A  simpler  method  of  making  these  solutions  is  to  use  tablets 

already  prepared  in  suitable  strength,  dissolving  one  in 

the  proper  quantity  of  physiological  salt  solution. 

3.  Novocaine  1-400: 

Fill  flasks  with  distilled  water  and  add  salt  to  make  normal 
saline.  Boil  twenty  minutes.  Add  novocaine  crystals 
and  boil  two  successive  days,  ten  minutes  each. 

4.  Quinine  and  urea  hydrochloride  1-200: 

Fill  flask  with  distilled  water  and  boil  twenty  minutes. 
When  cool,  add  sterile  quinine  and  urea  hydrochloride 
tablets.  Boil  ten  minutes.  Quinine  and  urea  do  not 
stand  boiling  as  well  as  novocaine. 

The  above  formulae  (3  and  4)  are  those  used  by  Dr.  Crile  in 
his  anoci-association  work. 

Formulae  for  antiseptic  solutions : 

1.  Bichloride  of  mercury : 

Bichloride  of  mercury 1.00  gm. 

Water 1000.00  c.c. 

This  makes  a  1-1000  solution  and  may  be  used  for  preparing 
the  surgeon's  hands,  the  field  of  operation,  etc. 


2.  Harrington's  solution : 

Commercial  alcohol  (94  per  cent.) 640.00  c.c. 

Hydrochloric  acid 60.00  c.c. 

Water 300.00  c.c. 

Bichloride  of  mercury 0.80  gm. 

Used  for  surgeon's  hands,  field  of  operation,  etc. 


3.  Iodine  and  alcohol : 

Tincture  of  iodine 50.00  c.c. 

Alcohol 50.00  c.c. 


176  MINOR  TECHNIC  IN  SURGICAL  NURSING 

Formulae  for  enemata: 

1.  1-2-3  enema: 

Magnesium  sulphate 5i 

Glycerine g  ii 

Water ' giii 

2.  2-4-8  enema: 

Magnesium  sulphate 5  ii 

Glycerine 3  iv 

Water g  viii 

3.  Oil  and  glycerine  enema: 

Glycerine 30.00  c.c. 

Olive  oil 90.00  c.c. 

Soapsuds 120.00  c.c. 

4.  Oxgall  and  glycerine  enema: 

Oxgall 8.00  c.c. 

Glycerine 120.00  c.c. 

Warm  water 500.00  c.c. 

Formulae  for  saline  solutions: 

1.  Physiological  salt  solution: 

Sodium  chloride 9.00  gm. 

Distilled  water  to 1000.00  c.c. 

2.  Ringer's  solution: 

Sodium  chloride 9.00  gm. 

Potassium  chloride 0.20  gm. 

Sodium  bicarbonate 0.20  gm. 

Distilled  water  to 1000.00  c.c. 

3.  Locke's  solution: 

Calcium  chloride 0.24  gm. 

Potassium  chloride 0.25  gm. 

Sodium  bicarbonate 0.20  gm. 

Sodium  chloride 9.00  gm. 

Glucose 1.00  gm. 

Distilled  water  to 1000.00  c.c. 

4.  Adler's  solution: 

Sodium  chloride 0.5900  gm. 

Potassium  chloride 0.0400  gm. 

Calcium  chloride 0.0400  gm. 

Magnesium  chloride 0.0250  gm. 

Sodium  phosphate 0.0126  gm. 

Sodium  bicarbonate 0.3510  gm. 

Glucose 0.1500  gm. 

Distilled  water 98.7914  c.c. 

These  four  formulae  represent  solutions  used  by  hypoder- 
moclysis  or  intravenous  infusion.  The  first  is  the  usual  solution 
and  the  other  three  are  examples  of  attempts  to  more  closely 
approximate  the  true  blood-serum. 


WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULAE       177 

Formulae  for  ointments  and  pastes : 

1.  Zinc  oxide  ointment: 

Zinc  oxide 20.00  gm. 

Bensoinated  lard 80.00  gm. 

2.  Unna's  paste: 

Gelatine 4  parts 

Water 10  parts 

Glycerine 10  parts 

Zinc  oxide 4  parts 

3.  Boracic  acid  ointment: 

Boracic  acid 10.00  gm. 

Paraffin 10.00  gm. 

White  vaseline 80.00  gm. 

4.  Paraffin  Wax  for  Burns  (Carrel) : 

Paraffin,  melting  point  126°  F 18  gm. 

Paraffin,  melting  point  105°  F 6  gm. 

Beeswax 2  gms. 

Castor  Oil 2  c.c. 

5.  Bismuth  paste: 

Bismuth  subnitrate 30.00  gm. 

White  Wax 5.00  gm. 

Soft  paraffin 5.00  gm. 

Yellow  vaseline 60.00  gm. 

Mix,  sterilize  in  autoclave.    Eucolyptol,  (2  per  cent.)  may  be  added  for 
its  antiseptic  effect. 
6  Chloramine-T  Paste  (Daufresne): 

Chloramine-T 10. 

Sodium  Stearate 75. 

Water 1000. 

This  is  an  "elegant"  preparation,  in  the  form  of  a  soft  cream,  for  the 
treatment  of  mildly  infected  wounds.  Its  preparation  is  difficult.  The  so- 
dium stearate  is  first  dissolved  in  the  water  which  must  be  hot.  Add  dilute 
HCL  to  the  solution  until  a  slight  cloudiness  appears.  The  solution  is  placed 
in  a  mechanical  mixer,  an  ice  cream  freezer  will  serve,  and  stirred  contin- 
uously until  the  paste  is  smooth.  The  container  should  be  about  two  thirds 
full,  and  surrounded  at  first  by  hot  water,  which  is  to  be  gradually  changed 
to  cold  during  the  process  of  agitation.  An  hour  or  more  will  be  required  for 
the  best  results.  When  a  smooth  paste  is  secured  the  chloramine-T  is  added 
and  the  stirring  continued,  very  slowly,  for  thirty  minutes  more.  The  paste 
will  keep  for  months. 

Formulae  for  vaginal  douches : 

1.  Lysol 10.00  c.c. 

Water  to  make 2000.00  c.c. 

2.  Alum  acetate 8.00  gm. 

Water. 2000.00  c.c. 

3.  Bichloride  of  mercury 1.00  gin. 

Water 2000.00  c.c. 

4.  Potassium  permanganate 2.00  gm. 

Water..  ..  2000.00  c.c. 


178  MINOR  TECHNIC  IN  SURGICAL  NURSING 

Baudot's  Depilatory  Powder. 

Fresh  unslaked  lime 10.00  gm. 

Sodium  sulphide  crystals 3.00  gm. 

Powdered  starch 10.00  gm. 

Rub  into  thick  paste  with  water  and  apply  about  %  inch 
thick.    Wash  off  after  five  minutes. 

Sinclair's  Glue. 

Glue  of  good  quality 50  parts 

Water 50  parts 

Glycerine,  or  Glucose,  or  Calcium  Chlorid .4  to    6  parts 

(more  in  cold  than  in  hot  weather) 

Menthol  or  Thymol "...  1  part 

Soak  the  glue  12  hours  in  cold  water.  Good  glue  will  not  be  dissolved 
but  will  form  a  coherent,  gelatinous  mass.  Melt  on  water  bath.  If  strongly 
acid  to  litmus  neutralize  with  sodium  hydrate.  After  each  reheating  a  little 
water  should  be  added. 

The  addition  of  Isinglass,  50  parts,  and  Tannic  acid,  12  parts,  is  said  to 
make  the  glue  more  elastic. 

Neutral  Soap. — A  neutral  soap  solution  is  used,  with  warm  sterile  water, 
for  washing  wounds  in  the  Carrel-Dakin  Treatment.  The  official  green  soap 
is  not  suitable  and  a  yellow  (resin)  soap  is  objectionable.  A  thin  solution  of 
white  soap  of  good  quality  (Ivory)  is  prepared  and  is  tested  for  free  alkali  as 
follows :  Mix  5  c.c.  of  the  soap  solution  with  5  c.c.  of  95  per  cent,  alcohol,  add 
3  drops  of  a  1  per  cent,  alcoholic  solution  of  phenolphthalein.  A  red  color 
indicates  the  presence  of  free  alkali.  Neutralize  the  soap  solution  with  dilute 
HCL,  adding  a  little  at  a  time  and  repeatedly  testing  as  above  until  the 
addition  of  the  phenolphthalein  fails  to  give  a  red  color. 

The  formulae  and  solutions  already  considered  deal  entirely 
with  the  handling  of  the  actual  medicament  in  its  full  strength. 
But  another  problem  presents  itself  when,  instead  of  the  pure 
drug,  a  more  or  less  concentrated  solution  thereof  is  the  prepara- 
tion to  be  used.  As  examples  of  these  concentrated  solutions, 
we  have  the  10  per  cent,  aqueous  solution  of  bichloride  of  mercury 
and  the  10  per  cent,  aqueous  solution  of  sodium  chloride  which 
are  the  stock  strengths  in  many  operating  rooms  from  which 
weaker  solutions  of  these  drugs  are  prepared.  And,  naturally, 
the  use  of  such  a  solution  somewhat  complicates  the  problem 
of  finding  the  amount  to  be  finally  used.  If  a  1-3000  solution 
of  bichloride  of  mercury  is  to  be  prepared  from  the  pure  drug, 
it  is  very  easy  to  see  that  there  must  be  one  part  of  the  drug  to 
every  3000  parts  of  the  final  solution,  or  one  gramme  of  the  drug 
in  every  3000  c.c.  of  the  solution.  But,  with  a  10  per  cent,  solu- 
tion as  a  starting  point,  the  problem  does  not  end  at  this  point. 
We  have  only  found  how  much  of  a  100  per  cent,  concentration 
of  the  drug  must  be  used.  But  we  do  know  that  10  per  cent,  is 


WEIGHTS,  MEASURES,  SOLUTIONS  AND  FORMULA       179 

only  y1^  of  100  per  cent.  Therefore,  ten  times  as  much  of  a  10  per 
cent,  solution  must  be  used  as  of  the  pure  drug.  In  other  words, 
instead  of  1  part  in  each  3000,  we  must  use  10  parts  in  each  3000. 
That  is,  we  use  10  c.c.  of  the  10  per  cent,  solution  in  each  3000 
c.c.  of  the  1-3000  solution.  In  approaching  the  salt  solution 
problem  of  preparing  a  ^  per  cent,  solution  from  a  10  per  cent, 
we  employ  the  same  method.  If  the  preparation  were  100  per 
cent,  strength,  we  should  have  to  use  9  parts  of  the  preparation 
in  each  1000  parts  of  the  solution  (as  •$>  per  cent,  equals  ^Q  of 
Y^-Q  ,  or  YoVo )  •  But  a  10  per  cent,  solution  is  only  ^  as  strong  as 
a  100  per  cent,  preparation  and,  therefore,  10  times  as  much  must 
be  used.  Therefore,  90  parts  of  the  10  per  cent,  strength  must  be 
used  in  each  1000  parts  of  the  solution.  But  90  parts  to  the  1000 
equals  9  parts  to  the  100.  Therefore,  9  c.c.  of  the  10  per  cent, 
strength  must  be  used  in  each  100  c.c.  of  the  solution. 

The  preparation  of  solutions  of  carbolic  acid  from  the  stock 
strength  of  5  per  cent,  is,  of  course,  identical  in  principle  with 
the  preceding  examples.  Suppose  that  a  3  per  cent,  solution  of 
carbolic  acid  is  required.  Using  the  pure  drug,  this  would  require 
3  parts  of  the  pure  drug  in  each  100  parts  of  the  solution.  But 
a  5  per  cent,  solution  is  only  yf  Q  as  strong  as  the  pure  drug.  So 
we  must  use  -Mj-^-  (i.  e.,  20)  times  as  much  of  the  5  per  cent,  solu- 
tion as  of  the  pure  drug.  That  is  to  say,  we  must  use  60  parts 
of  the  5  per  cent,  strength  to  each  100  parts  of  the  solution. 

A  study  of  these  three  examples  gives  us  the  three  steps 
followed  in  preparing  solutions  from  other  solutions  of  greater 
strength.  (1)  Find  what  part  of  the  required  solution  the  pure 
drug  would  represent.  (2)  Multiply  this  by  the  denominator  of 
the  fraction  that  represents  the  strength  of  the  stock  solution. 
(3)  Divide  this  result  by  the  numerator  of  the  same  fraction. 
The  last  step  will  be  unnecessary  when  the  numerator  is  1. 
The  amount  thus  obtained  is  then  measured  and  to  it  is  added 
enough  of  the  solvent  (usually  water)  to  give  the  total  quantity 
of  solution  required. 


CHAPTER  XIII 

CHARTS  AND  RECORDS 
I.  THE  CHART 

THE  proper  keeping  of  the  chart  giving  full  details  of  the 
patient's  condition,  of  what  has  been  done  and  is  being  done  for 
her,  and  the  entire  history  of  the  patient  from  the  beginning  of 
her  illness  is  one  of  the  most  exacting  of  the  duties  that  fall  to 
the  share  of  the  nurse, — either  in  hospital  work  or  in  private 
practice.  The  hospital  chart  is  generally  much  fuller  than  that 
used  in  private  nursing, — and,  as  a  result,  requires  more  attention. 
A  full  chart  consists  of  a  number  of  sheets  for  different  purposes, 
mounted  on  a  board  with  a  clip  for  holding  the  sheets  in  place. 
These  sheets  are  arranged  according  to  a  definite  system  in  differ- 
ent hospitals,  and  may,  indeed,  be  different  in  character  and 
requirements.  As  a  basis  for  description,  a  full  chart  that  covers 
the  entire  field  of  diagnosis,  treatment  and  daily  progress  will 
be  considered  at  this  time.  While  some  of  the  sheets  mentioned 
will  be  such  as  to  be  omitted  in  some  charts,  yet  the  entire  number 
will  be  necessary  in  every  case  of  operative  character  in  which 
a  full  history  has  been  taken  and  a  thorough  examination, 
both  physical  and  pathological,  made.  The  arrangement  of  the 
sheets  for  reference  will  be  used,  as  this  is  the  form  of  practical 
importance  to  the  nurse  rather  than  the  order  in  which  they  are 
filed  away  among  the  hospital  records. 

1.  Cover  Sheet. — This  is  generally  a  blank  piece  of  white 
paper,  upon  which  the  name  of  the  patient,  date  of  admittance, 
ward  and  name  of  attending  physician  are  to  be  written.    It  is 
used  merely  as  a  cover  for  the  remainder  of  the  chart,  with  the 
double  purpose  of  protecting  the  next  page  and  preventing  any 
one  from  seeing  the  other  data  without  taking  the  chart  for 
examination. 

2.  Temperature  Sheet. — This  sheet  has  a  space  at  the  top 
or  side  for  the  patient's  name  and  the  date  and  is  so  divided  off 
into  spaces  that  a  record  of  the  patient's  temperature,  pulse  and 
respiration  may  be  kept  upon  it,  as  well  as  a  summary  as  to  the 
condition   of  her  bowels   and  kidneys.     The   temperature,   as 
recorded  on  this  sheet  in  the  average  case,  is  generally  merely 

180 


CHARTS  AND  RECORDS 


181 


the  morning  and  evening  record 
(Fig.  75).  It  may,  however,  be 
divided  into  spaces  with  red 
ink  lines  so  as  to  be  used  for 
every  four-hour  recording  (Fig. 
76).  This  sheet  gives  to  the 
physician,  at  one  glance,  a  pic- 
ture of  the  patient's  tempera- 
ture and  pulse  record  from  the 
time  of  her  admittance  to  the 
hospital. 

3.  Record  Sheet.— This  sheet 
has  at  its  top  space  for  the 
name  of  the  patient  and  the 
date.  Its  contents  are  more 
comprehensive  and  minute  than 
those  of  the  temperature  sheet. 
It  is  divided  vertically  into  a 
number  of  columns,  each  with 
a  heading  to  indicate  the  kind 
of  information  that  is  to  be  re- 
corded in  that  particular  place 
(Fig.  77).  Through  each  24 
hours,  as  nourishment  is  given, 
or  medicine  administered;  as  the 
bowels  or  bladder  act;  as  the 
temperature  rises  or  falls,  the 
time  and  all  other  details  are 
recorded  in  the  proper  columns 
on  this  sheet.  The  temperature, 
pulse  and  respiration  are  gener- 
ally taken  every  four  hours 
when  using  this  sheet,  although, 
in  very  serious  cases,  a  two-hour 
temperature  record  maybe  kept. 
As  will  be  readily  understood,  a 
sheet  of  this  kind  has  much 
data  that  would  not  be  required 
in  the  simplest  cases.  It  is, 
therefore,  used  only  in  opera- 


Fio.  75. — Chart  showing  morning  and  even- 
ing temperature.     (Septic  peritonitis.) 


182 


MINOH  TECHNIC  IN  SURGICAL  NUHSING 


« 


od 


FIG.  76.— Four-hour  chart.     (Septicopysemia.) 

tive  cases  and  those  where  there  is  an  elevation  of  temperature 
that  requires  watching.     At  the  end  of  24  hours,  the  material 


CHARTS  AND  RECORDS 


183 


gathered  on  the  record  sheet  is  totaled  so  as  to  give  in  a  brief 
summary  those  facts  of  importance  during  the  time  covered. 

It  is  well  that  we  should  remark  at  this  time  upon  one  or  two 
points  of  special  interest  and  importance  in  the  recording  of  data. 
The  two  points  upon  which  particular  emphasis  will  be  placed 
are  the  recording  of  bowel  and  bladder  evacuations.  The  first 
of  these  is  particularly  important  in  those  cases  where  there 
seems  the  possibility  of  intestinal  obstruction,  and  the  patient 

Date Sheet  No 

Name.  . 


Date 

Hour 

Nourishment 

Medication 

Remarks 

Def. 

Urine 

7/7/15. 

8.30 

Morphine  su 

Iph.  gr.  Je\    On  leaving  for 

Atropine  sulph.  gr.J4o/operat  ing  room 

10.30 

Returned  from  O.  R. 

Pulse  good. 

11.20 

Fully  reacted. 

1.00 

Water  5i. 

Retained. 

8.00 

Voided. 

5viii 

8.00 

Complains  of  slight  pain 

in  region  of  incision. 

10.00 

Crushed  ice. 

Voided. 

3iv 

12.00 

Sleeping. 

7/8/15. 

2.00 

Voided. 

5ix 

4.00 

Water  ad  lib. 

Turned  p.  r.  n. 

6.00 

Comfortable  night. 

Twenty-four-hour  summary. 

Water  ad  lib. 

Morphine  sulph.  gr.  %\    On  leaving  for 

Crushed  ice. 

Atropine  sulph.  gr.  KsoJ  operating  room 

Voided. 

3xxi 

Turned  p.  r.  n. 

Comfortable  night. 

Fid.  77. — Type  of  record  sheet.    The  more  usual  form  has  column  for  recording  tempera- 
.  ture,  pulse,  and  respiration. 

should  be  carefully  watched  during  such  times  to  decide  whether 
or  not  gas  is  passed.  Of  course,  this  caution  applies  particularly 
after  the  administration  of  an  enema,  as  there  is  very  little  likeli- 
hood of  a  patient  with  suspected  obstruction  passing  gas  at  any 
other  time.  In  regard  to  the  bladder  function,  attention  must 
be  called  to  the  occasional  error  of  recording  the  fact  that  the 
patient  has  voided  involuntarily  and  not  giving  the  amount  (or 
approximate  amount)  voided.  This  may  seem  an  impossibility 
when  the  urination  is  involuntary,  but  it  is  simple  enough  to  tell 


184  MINOR  TECHNIC  IN  SURGICAL  NURSING 

whether  or  not  the  amount  passed  was  a  mere  dribble  or  a  large 
quantity.  The  importance  of  accuracy  in  this  matter  lies  in 
the  possibility  of  the  patient,  instead  of  having  incontinence  of 
urine  in  the  accepted  meaning  of  this  term,  being  the  victim  of 
retention  with  overflow.  In  cases  of  this  sort,  the  dribble  that 
is  forced  out  may  give  the  impression  of  incontinence,  while  the 
patient  has,  in  fact,  a  bladder  distended  with  forty  or  fifty  ounces 
of  urine. 

4.  Medicine  and  Treatment  Sheet. — This  sheet  (Fig.  78),  as 
the  other,  has  a  place  at  the  top  for  the  name  of  the  patient.  It 
should  be  divided  into  five  vertical  columns  for  the  recording  of 
the  following  data:  date  ordered;  time  ordered;  medicament, 
frequency  and  manner  of  administration;  and  date  when  dis- 
continued. This  gives  at  a  glance  just  what  the  patient  is  re- 
ceiving in  the  line  of  medicine  and  treatments,  and  whether  or 
not  any  of  them  have  been  discontinued. 

In  addition  to  the  four  sheets  already  mentioned  and  de- 
scribed, there  are  four  that  are  for  the  use  of  the  house  staff  of  the 
hospital.  These  are:  (1)  the  history  blank,  for  the  brief  out- 
lining of  the  salient  points  of  the  history  of  the  disease  from  which 
the  patient  suffers,  with  additional  spaces  for  a  brief  record  of 
the  treatment  of  an  operative  sort;  (2)  the  history  sheet  for  the 
full  and  careful  recording  of  the  past  and  present  history  of  the 
patient's  condition;  (3)  the  urinalysis  sheet  for  the  recording  of 
the  results  of  the  examination  of  such  specimens  of  urine  as  may 
be  sent  to  the  laboratory;  and  (4)  the  pathological  sheet  for  the 
recording  of  the  results  of  the  examination  of  such  pathological 
specimens  as  may  have  been  sent  up  for  diagnosis.  The  specimens 
under  the  latter  head  may  be  blood,  faeces,  sputum,  stomach 
contents,  or  any  removed  tissues.  The  four  last  mentioned 
sheets  should  be  placed  on  the  chart  at  the  back,  when  it  is  first 
made  up  for  use.  If  it  chances  that  they  are  not  used,  they  may 
be  later  removed. 

In  some  hospitals  there  is  another  special  sheet  employed 
during  that  period  which  an  operative  case  spends  in  the  recovery 
room.  The  regular  ward  order  book  is  not  here  convenient  for 
the  writing  of  orders  for  the  patient,  and  the  stay  is  frequently 
very  abbreviated  before  transference  to  the  ward.  A  supple- 
mentary sheet,  ruled  so  as  to  have  columns  for  date,  hour  and 
order,  is  supplied  and  kept  on  the  chart.  All  orders,  prior  to 
patient's  removal  to  ward,  are  written  on  this  sheet  and,  thus, 


CHARTS  AND  RECORDS 


185 


Date. 


Name. 


No... 

Sheet  No. 


6/23/15. 
6/24/15. 

* 

6/25/15. 

6/26/15. 
2.15P.M 
9.00P.M 

6/27/15. 

6/28/15. 

7/3/15. 
7/6/15. 


Send  specimen  of  urine  to  laboratory. 
Ol.  ricini  3i  at  9  A.M.  to-morrow. 
Liquid  diet. 
B. 

Prepare  for  operation  at  9  A.M. 
S.  S.  enema  in  A.  M. 

Morphine  sulphate  gr.  %',  atropine  sulphate  gr.  KM  by  hypo., 
before  leaving  for  operating  room. 

B. 

Hot  water  ad  lib. 

Catheterize  in  8  hours  if  necessary. 
Morphine  sulphate  gr.  l/6  by  hypo,  now,  and  repeat  if  necessary. 

Liquid  diet,  without  milk. 

B. 
S.  S.  enema  now. 

G. 
Morphine  sulphate  gr.  %  by  hypo. 

B. 
Catheterize  p.  r.  n. 

E.  E.  M. 
1-2-3-enema  in  A.M. 

G. 
Soft  diet. 

S.  D.  B. 
Urotropin  gr.  xv  t.  i.  d. 

B. 

Pil.  A.  B.  &  S.  No.  ii  q.,  P.M. 
Specimen  of  urine  to  laboratory  in  A.M. 

G. 

Light  diet.     Irrigate   bladder   b.  i.  d.  with  2  per  cent,  boracic 
acid  solution,  until  clear  return.    At  completion  of  irrigation, 
instil  and  leave  argyrol  (15  per  cent.)  5ss. 
S.  D.  B. 


FIG.  78. — Medicine  and  treatment  sheet. 

return  to  the  ward  with  the  chart  and  such  orders  as  have  not 
been  discontinued  are  conveniently  recorded  for  continued 
execution. 

A  careful  study  of  the  illustrated  sheets  will  give  a  good  idea 
of  how  the  various  records  appear  in  practical  work. 

A  full  chart,  on  any  serious  case,  would  thus  consist,  at  the 
beginning,  of  eight  sheets.  As  the  condition  progresses,  succes- 
sive additions  are  made  as  the  record  increases,  and,  after  opera- 
tion, the  necessary  recovery  ward  sheet  is  added. 


PART  IV— THE  PATIENT 


CHAPTER  XIV 

OBSERVATION 
I.  THE  NURSE  AS  AN  OBSERVER 

A  VERY  important  part  of  the  work  of  the  nurse  consists  in 
the  observation  of  the  symptoms  and  condition  of  the  patient 
during  the  absence  of  the  physician  or  surgeon.  The  doctor 
sees  the  patient  once  or  at  most  twice  in  the  twenty-four  hours, 
and  then  only  for  a  few  minutes.  For  a  knowledge  of  what  hap- 
pens in  the  intervals  he  is  dependent  on  the  nurse,  and  while  he 
is  absent  many  things  may  occur  of  the  greatest  importance  in 
relation  to  the  diagnosis,  prognosis,  and  treatment  of  the  case. 
It  may  be  noted  in  the  first  place  that  the  object  of  the  observa- 
tions made  by  the  nurse  is  quite  different  from  that  of  those 
made  by  the  surgeon.  His  primary  purpose  is  the  diagnosis  of 
the  condition,  and  his  chief  attention  is  given  to  the  facts  which 
have  a  bearing  upon  that  problem.  The  nurse  is  not  directly 
concerned  with  the  diagnosis,  that  is  not  her  business,  although 
her  observations  may  often  help  materially  to  that  end.  The 
primary  object  of  the  nurse's  observations  is  the  discovery  of 
premonitory  symptoms,  which  foretell  a  change  in  the  course  of 
the  disease  or  the  coming  of  a  complication.  In  surgery  the 
work  of  the  nurse  as  an  observer  is  of  supreme  importance  in 
the  period  of  morbidity  and  of  hazard  following  an  operation. 
The  character  and  meaning  of  the  symptoms  to  be  noted  by  tne 
nurse  in  connection  with  post-operative  complications  will  be 
considered  in  a  separate  chapter.  In  this  place  we  shall  discuss 
the  meaning  and  the  methods  of  observation  itself  and  a  brief 
outline  of  the  field  of  observation  within  the  province  of  the 
surgical  nurse. 

II.  THE  MEANING  OF  OBSERVATION 

Observation  means  the  act  of  noting  intelligently  some  fact 
or  occurrence  that  is  pertinent  to  the  subject  matter  under  con- 
sideration or  to  the  work  in  hand.  In  practice  the  observer, 
whether  in  scientific  investigation  or  in  technical  work  of  any 
kind,  is  required  to  do  three  things :  (1)  to  observe,  (2)  to  measure, 
(3)  to  record.  To  observe  properly  requires,  in  the  first  place, 
knowledge.  Simply  to  see  or  hear  or  touch  a  thing  is  not  to 

189 


190  THE  PATIENT 

observe  it.  Observing  implies,  not  indeed  full  knowledge  of  what 
the  thing  seen  means,  but  at  least  a  recognition  of  the  fact  that 
it  has  a  probable  meaning  pertinent  to  the  matter  in  hand.  The 
greater  the  ignorance  of  the  observer,  the  greater  is  the  certainty 
that  he  will  overlook  important  facts  and  occurrences.  The 
wider  his  knowledge,  the  more  certain  it  is  that  he  will  note  all 
the  facts  that  have  a  bearing  on  the  case.  The  second  requisite 
for  a  good  observer  is  attention,  for  this  means  clearness  of  the 
impression  received  from  seeing,  hearing  or  feeling  the  thing 
observed,  and  the  third  is  interest,  for  without  interest  continued 
attention  is  difficult  if  not  impossible.  Finally,  the  observer 
must  possess  an  attribute  which  is  perhaps  the  most  important 
of  all  and  at  the  same  time  the  most  difficult  to  attain.  It  is 
that  attitude  of  mind  which  permits  its  possessor  to  be  satisfied 
with  nothing  else  than  the  exact  truth,  without  regard  to  its 
agreement  with  preconceived  ideas  or  personal  wishes.  It  is  so 
easy  to  deceive  ourselves  into  the  belief  that  we  see  something 
that  we  wish  to  see,  or  that  we  strongly  expect  to  see.  An  obser- 
vation that  is  inaccurate  is  worse  than  useless,  because  it  is 
misleading.  The  need  for  accuracy  also  makes  it  imperative 
that  the  phenomena  observed  should  be  measured  whenever 
possible,  and  that  the  result  of  the  observation  should  be  set 
down  in  writing  at  the  time  it  is  made,  for  memory  unaided  is 
an  untrustworthy  repository  for  facts. 

,  III.  METHOD  IN  OBSERVATION 

System  and  a  regular  plan  of  procedure  are  essential  to 
thoroughness  and  completeness  in  any  undertaking.  If  the  obser- 
vations of  the  nurse  are  made  only  when  some  symptom  or 
change  in  the  patient's  condition  forces  itself  upon  her  attention, 
many  important  facts  will  quite  certainly  be  overlooked  or  dis- 
covered too  late  to  save  the  patient,  it  may  be,  from  unpleasant 
consequences.  For  this  reason  the  nurse  should  learn  to  follow 
as  far  as  possible  a  definite  plan  in  her  observations  of  the  patient's 
condition.  This  means  that  she  should  direct  her  attention  suc- 
cessively and  at  suitable  intervals  of  time  to  different  aspects 
of  the  case,  so  that  all  the  ground  may  be  covered  thoroughly, 
and  no  important  new  development  escape  her  notice.  Thus  the 
temperature  is  taken  and  the  pulse  and  respiration  counted  at 
regular  hours,  varying  with  the  gravity  of  the  condition.  The 
character  and  amount  of  the  excretions  are  regularly  noted. 


OBSERVATION  191 

Known  danger  signals  that  are  likely  to  appear  should  be  borne 
in  mind,  and  the  attention  deliberately  directed  to  determine 
their  presence  or  absence  often  enough  to  ensure  their  prompt 
discovery.  Different  regions  of  the  body  should  be  inspected 
regularly  according  to  the  circumstances  of  the  case,  as  the  abdo- 
men for  distention,  the  back  for  bed-sores,  the  bandages  for 
staining  with  blood  or  other  discharges,  etc.  Symptoms  that 
tend  to  gradual  increase  should  be  noted  at  stated  intervals, 
and  those  that  tend  to  recur  at  certain  periods  should  be  looked 
for  at  the  proper  time.  Attention  should  be  directed  from  time  to 
time  to  detect  disturbances  of  the  circulatory,  respiratory,  diges- 
tive, genito-urinary,  and  nervous  systems.  When  a  symptom  is 
obscure  or  its  presence  doubtful,  repeated  observations- should  be 
made  from  time  to  time,  to  verify  or  correct  the  first  impression,with 
intervals  between  the  observations  during  which  the  attention  is 
directed  to  other  matters.  Observations  should  be  systematically 
entered  on  the  records,  and  these  should  be  kept  fully  up  to  date. 

IV.  THE  SIGNIFICANCE  OF  SYMPTOMS 

The  inexperienced  nurse  will  often  be  at  a  loss  to  determine 
whether  a  symptom  has  any  significance  at  all,  or  in  other  cases 
whether  it  is  of  such  importance  that  the  surgeon  should  be 
informed  at  once.  Facts  that  have  no  bearing  on  the  case  should 
not  be  recorded.  Their  presence  in  the  record  is  not  only  useless 
but  confusing.  To  enter  an  observation  that  is  not  pertinent  to 
the  case,  or  to  summon  the  doctor  unnecessarily,  is  a  humiliating 
confession  of  inexperience.  To  omit  the  record  of  an  important 
symptom,  or  to  fail  to  send  for  the  doctor  at  the  earliest  appear- 
ance of  a  danger  signal,  is  not  only  a  confession  of  inexperience 
but  a  grave  dereliction  of  duty.  There  are  occasions  when  the 
experienced  nurse,  or,  for  that  matter,  the  experienced  surgeon, 
may  be  puzzled  to  determine  offhand  whether  a  certain  symptom 
has  any  significance,  and  the  first  rule  of  conduct  is,  "  When  in 
doubt  act  always  on  the  safe  side."  There  are,  however,  certain 
considerations  which  will  assist  the  nurse  in  deciding,  as  to  the 
importance  of  a  symptom. 

1.  Severity. — Every    severe    symptom    is    of    importance, 
whether  its  relation  to  the  case  is  apparent  or  not. 

2.  Duration. — A  slight  or  moderate  symptom  that  is  tran- 
sient may  mean  little  or  nothing,  but  if  it  persists  it  should 
receive  serious  consideration.    Hiccough  as  a  transient  symptom 


192  THE  PATIENT 

is  of  no  moment,  but  persistent  hiccough  in  some  cases  of  disease 
is  a  symptom  of  the  gravest  import. 

3.  Tendency  to   Recur. — A  symptom  that  tends  to  recur 
persistently  may  be  regarded  as  having  significance. 

4.  Progressive  Development. — A  symptom  that  increases  in 
severity  from  hour  to  hour  is  always  important. 

5.  Known  Character  as  a   Danger  Signal. — For  example,  a 
sudden  abdominal  pain,  whether  severe  or  not,  occurring  in  the 
third  week  of  typhoid  is  very  likely  to  mean  a  perforation,  and 
the  physician  should  be  called  at  once. 

6.  Relation  to  affected  region,  or  to  the  physiological  system 
involved  in  the  disease.    For  example,  all  digestive  or  abdominal 
symptoms  are  important  after  a  laparotomy. 

7.  Association    with    Other   Symptoms. — A   symptom   that 
would  be  of  no  importance  by  itself  may,  when  associated  with 
other  symptoms  in  a  group  that  is  known  to  have  a  definite 
meaning,  become  of  the  utmost  significance.     A  sigh,  even  if 
often  repeated,  is  not  a  symptom  of  importance  by  itself,  but 
sighing  respiration  associated  with  great  restlessness,  anxious 
expression  of  the  face,  progressive  pallor,  etc.,  means  that  a 
dangerous  hemorrhage  is  going  on. 

8.  Disposition  of  the  Patient.— Jn  estimating  subjective  symp- 
toms the  tendency  of  the  patient  to  exaggerate  or  minimize  his  sen- 
sations must  be  taken  into  account.    Physical  evidences  outweigh 
his  statements  if  they  contradict  them,  but  at  the  same  time  the 
patient's  sincere  complaints  should  never  be  too  lightly  regarded. 

V.  THE  CONDITIONS  WHICH  REQUIRE  THAT  THE  SURGEON 
SHOULD  BE  CALLED 

These  cannot  be  defined  with  exactness.  They  may  be  briefly 
summarized  as  follows : 

1.  When  the  presence  of  any  danger  signal,  or  premonitory 
symptom  of  a  serious  complication,  is  recognized. 

2.  When  a  progressive  change  for  the  worse  is  taking  place 
in  the  patient's  condition. 

3.  When  a  severe  symptom  arises  not  provided  for  in  the 
orders  already  received. 

4.  When  the  nurse  is  in  doubt. 

When  going  to  the  telephone  to  summon  the  surgeon  the  nurse 
should  be  prepared  to  answer  any  questions  as  to  the  patient's 
condition  since  his  last  visit. 


OBSERVATION  193 

VI.  OBJECTIVE  SYMPTOMS  AND  SIGNS 

Every  symptom  is  either  objective  or  subjective  in  character. 
An  objective  symptom  is  one  that  is  manifest  to  the  observer 
through  any  of  the  senses,  usually  of  sight,  hearing,  or  touch. 
The  patient  may  or  may  not  be  aware  of  it.  A  full  enumeration 
and  discussion  of  objective  symptoms  would  require  a  volume 
in  itself.  Many  of  them  must  be  observed  and  recorded  by  the 
surgeon  or  physician  rather  than  by  the  nurse.  Those  symptoms 
(whether  subjective  or  objective)  which  do  lie  within  the  field 
of  observation  of  the  nurse  are:  (1)  temperature,  pulse,  and  respi- 
ration, (2)  initial  symptoms  which  mark  the  onset  of  a  disease, 
(3)  premonitory  symptoms  which  foretell  the  coming  of  a  compli- 
cation, (4)  symptoms  whose  fluctuations  from  hour  to  hour  are 
significant,  (5)  symptoms  of  sudden  development.  The  initial, 
premonitory,  and  other  symptoms  which  are  of  particular  sig- 
nificance in  the  work  of  the  surgical  nurse  are  considered  else- 
where. We  can  do  little  more  here  than  present  a  list  of  some  of 
the  more  important  objective  symptoms  and  signs  without  at- 
tempting to  discuss  them. 

There  are  four  symptoms  which  are  of  unique  value  in  the 
study  of  disease.  Three  of  these  have  been  for  many  years  the 
most  constantly  observed  of  all  symptoms,  while  the  fourth  is 
rapidly  coming  to  be  recognized  as  of  equal  importance  with  the 
others,  particularly  to  the  surgeon.  They  may  be  called  the 
index  symptoms,  since  they  are  always  present,  they  can  be 
readily  measured  with  accuracy,  they  are  subject  to  rapid  varia- 
tions, responding  promptly  in  many  cases  to  changes  in  the 
progress  of  the  disease,  and  their  recorded  measurements  present 
a  fair  index  of  the  patient's  condition.  They  are :  (1)  the  tempera- 
ture of  the  body,  (2)  the  respiration,  (3)  the  pulse,  (4)  the  blood- 
pressure. 

The  temperature  and  the  blood-pressure  have  each  only  one 
element  to  be  considered.  It  is  the  rise  or  fall  measured  on  a 
scale  in  degrees  of  temperature  in  one  case  and  in  millimetres  of 
mercury  in  the  other.  In  the  case  of  the  pulse  and  respiration 
there  are  other  elements  beside  frequency  to  be  considered,  so 
that  each  of  these  presents  a  group  of  symptoms  rather  than  a 
single  one.  Changes  in  the  regularity  and  volume  of  the  pulse, 
as  well  as  its  rate,  are  to  be  observed,  and  the  respiratory  system 
presents  a  large  group  of  symptoms  in  addition  to  the  frequency 
of  respirations.  Observation  of  the  blood-pressure  must  be  made 
13 


194  THE  PATIENT 

by  means  of  a  special  and  rather  complicated  instrument  and 
is  usually  done  by  the  physician.  A  falling  blood-pressure 
is  the  most  reliable  premonitory  symptom  of  shock,  and  is  of 
special  value  on  the  operating  table. 

Certain  objective  signs  with  regard  to  the  general  aspect  of 
the  patient  are  to  be  observed.  The  position  of  the  body  is 
sometimes  significant.  It  may  be  relaxed  and  flaccid  from  weak- 
ness, or  stiff  and  rigid  from  pain,  with  knees  drawn  up  to  relieve 
hip  or  abdominal  painr  sitting  up  through  inability  to  breathe 
lying  down  (orthopncea) ,  curled  up  on  one  side  through  inability 
to  lie  on  the  other  side  or  back,  with  arms  thrown  over  the  head 
to  assist  breathing  in  air  hunger,  etc. 

The  expression  of  the  face  is  important  in  certain  cases. 
Dulness,  apathy,  or  lack  of  expression  is  seen  in  shock,  in  extreme 
weakness,  and  in  toxaemia  with  fever.  The  so-called  "  anxious 
expression  "  is  of  special  importance.  It  is  difficult  to  describe 
but  readily  recognized  when  seen.  It  occurs  in  several  acute 
affections  of  sudden  development  and  grave  import,  such,  for 
example,  as  obstructed  breathing,  peritonitis,  and  particularly 
hemorrhage. 

Movements  of  the  body  may  require  to  be  noted,  such  as 
restricted  movements  from  tenderness  in  joints  or  muscles,  rest- 
lessness, tossing  and  turning  from  side  to  side,  twitching  of  mus- 
cles, spasms,  and  convulsions. 

Changes  in  the  color  of  the  skin  should  be  observed.  Chronic 
pallor  will  be  observed  and  recorded  by  the  physician  in  the 
history  of  the  case.  Acute  or  sudden  pallor  may  be  transient, 
as  in  nausea,  or  lasting  or  perhaps  progressive,  as  in  shock  and 
hemorrhage.  The  pallor  has  a  yellowish  tinge  in  profound 
anaemia,  in  slow,  long-continued  hemorrhage,  and  after  a  severe 
acute  hemorrhage.  It  is  a  bluish  pallor,  due  to  the  blood  settling 
in  the  small  veins,  in  shock,  and  at  the  beginning  of  an  acute 
hemorrhage.  Cyanosis  is  the  bluish  color  of  the  skin,  such  as  is 
seen  in  the  face  after  holding  the  breath.  It  means  lack  of 
oxygen  in  the  blood,  and  is  usually  associated  with  difficult 
breathing  (dyspnoea).  The  yellow  color  of  jaundice  is  a  chronic 
symptom  and  will  be  recorded  by  the  physician.  Excessive 
dryness  or  moisture  of  the  skin  may  call  for  notice,  particularly 
the  drenching  sweats  that  occur  in  septic  infection,  usually 
during  sleep.  Local  swelling  of  the  skin,  without  redness,  may 
be  due  to  oedema,  a  watery  infiltration,  or,  rarely,  to  emphysema; 


OBSERVATION  195 

that  is,  an  infiltration  with  air  or  gas.  This  latter  condition  occurs 
sometimes  when  the  lung  has  been  wounded,  the  air  finding  its 
way  into  the  subcutaneous  tissues.  Infection  with  the  gas 
bacillus  also  produces  it.  On  pressure  the  skin  yields  with  a 
soft  crackling  that  can  be  felt  and  heard,  or  the  skin  may  become 
so  tense  with  gas  that  tapping  on  it  gives  a  drum-like  note. 
When  observed  it  should  be  reported  at  once.  The  abdomen 
should  be  observed,  particularly  as  regards  distention  with  gas, 
after  operations  involving  the  peritoneum. 

The  following  observations  should  always  be  recorded  by  the 
nurse : 

Symptoms  connected  with  the  nervous  system:  excitement, 
delirium,  mental  dulness  and  slowness  in  response,  excessive 
weakness,  unconsciousness,  coma. 

Sleep:  its  time,  duration,  and  character,  quiet,  restless,  with 
sudden  startings,  etc. 

Chills:  time,  duration,  severity,  degree  of  cyanosis  if  present. 

Vomiting:  time,  amount,  character,  including  consistency 
(watery,  mucous,  particles  of  food,  fresh  blood,  coffee-ground 
material,  due  to  altered  blood,  etc.) ;  color  (watery,  yellow,  brown, 
green,  etc.) ;  eructations  of  gas,  regurgitation  (spitting  up  mouth- 
fuls  of  fluid),  etc. 

The  excretions:  perspiration  if  excessive;  urine,  time  when 
voided,  amount  (measured)  and  character  if  abnormal  (very  dark 
in  color,  very  cloudy,  bloody,  containing  sediment,  very  strong 
odor,  etc.). 

Vaginal  discharges,  including  the  occurrence  of  menstruation. 

Movements  of  the  bowels:  simply  the  number  and  time  if 
normal.  The  character  should  be  noted  if  abnormal  in  any 
respect  (fluid,  watery,  watery  with  particles,  bloody,  containing 
mucus,  undigested  food,  etc.);  the  color,  if  black  from  the  pres- 
ence of  altered  blood  or  clay  colored  from  the  absence  of  bile. 
After  an  operation  for  gall-stone  disease,  with  common  duct 
obstruction  and  jaundice,  particularly  when  the  stools  have  been 
clay  colored  before  the  operation,  the  color  of  the  stools  should 
be  regularly  noted  during  the  period  of  morbidity.  The  result 
of  enemas  should  be  recorded  (retained  or  partly  retained,  not 
returned,  returned  clear,  returned  discolored,  yellow  or  brown, 
slightly  or  moderately,  etc.,  with  few  or  many  particles  or  hard 
masses,  etc.).  "  Good  result  "  on  the  record  means  a  liquid  or 
partly  formed  stool  normal  in  amount  and  character. 


196  THE  PATIENT 

VII.  SUBJECTIVE  SYMPTOMS 

Subjective  symptoms  are  those  that  are  manifested  only  in 
•  the  consciousness  of  the  patient.  They  are,  in  other  words,  the 
sensations  and  feelings  experienced  by  the  patient.  We  may 
divide  them  into  four  groups:  (1)  symptoms  affecting  the  special 
senses  (sight,  hearing,  touch,  taste,  smell),  (2)  pain,  (3)  organic 
sensations,  (4)  feelings. 

1.  Symptoms  connected  with  the  special  senses  are  important 
in  the  specialties  which  deal  with  diseases  of  the  eye  and  ear 
and  nervous  system,  and  in  some  instances  in  general  surgery, 
but  they  belong  as  a  rule  within  the  field  of  observation  of  the 
doctor  rather  than  the  nurse. 

2.  Pain  is  the  most  universally  recognized  symptom  of  disease. 
Its  office  seems  to  be  principally  that  of  directing  the  attention 
insistently  to  the  seat  of  the  disease  or  injury.    It  varies  in  inten- 
sity in  every  grade,  from  barely  noticeable  pain  to  pain  so  ago- 
nizing that  loss  of  consciousness  ensues.  It  varies  also  in  character. 
We  have  many  words  descriptive  of  pain,  the  aptness  of  which 
every  one  recognizes,  such  as  sharp,  dull,  aching,  gnawing,  boring, 
shooting,  throbbing,  smarting,  burning  pain,  etc.     One  striking 
characteristic  of  pain  is  its  distinct  localization.     There  is  no 
such  thing  as  general  pain,  although  pain  is  sometimes  felt  as 
more  or  less  vaguely  diffused  through  a  part  of  the  body.    Pain 
may  be  continuous  or  paroxysmal  (coming  "  in  spells  ").    It  may 
be  constant  or  elicited  only  on  movement  or  pressure  (tenderness). 
Pain  may  be  felt  at  the  seat  of  disease  or  "  referred  "  to  some 
other  area,  or  both.    Examples  of  referred  pain  are  the  pain  felt 
in  the  knee  in  hip  disease,  and  that  under  the  left  shoulder-blade 
in  gall-stone  disease.    Wherever  inflammation  is  present  localized 
pain  associated  with  tenderness  is  always  felt.    When  reporting 
a  complaint  of  pain  on  the  part  of  the  patient,  its  exact  location 
should  be  given.     First  the  region  of  the  body  should  be  men- 
tioned, head,  neck,  chest,  abdomen,  back,  arm,  forearm,  hand, 
thigh,  leg,  foot;  then  the  part  of  the  region  affected,  back  or 
front;  upper,  lower  or  middle  part;  also  whether  on  the  left  or 
right,  outer  or  inner  side.    If  pain  in  the  wound  or  in  a  joint  is 
complained  of,  only  the  affected  part  need  be  mentioned.    The 
character  of  the  pain  should  be  given  in  the  patient's  own  descrip- 
tive words. 

3.  Organic  sensations  are  those  connected  with  the  internal 
organs,  such  as  hunger,  thirst,  want  of  appetite  (distaste  for  food), 


OBSERVATION  197 

(the  sense  of  having  had  enough);  nausea,  sensations  of  fulness 
or  emptiness  in  the  region  of  the  stomach;  the  desire  to  micturate 
or  go  to  stool  and  their  abnormal  forms  (dysuria,  strangury, 
tenesmus);  vertigo,  swimming  in  the  head,  sensations  of  vague 
discomfort  in  one  region  or  another,  etc.  Organic  sensations  are 
characterized  by  being  very  vaguely  localized.  They  vary  in 
intensity  but  not  so  sharply  or  through  such  an  extended  scale 
as  in  the  case  of  pain.  When  very  intense  they  merge  into  painful 
sensations.  Some  of  these  mentioned  are  physiological  and 
natural,  and  become  symptoms  only  when  exaggerated  or  sup- 
pressed. 

4.  Feeling  means  strictly  the  experience  of  pleasantness  or 
unpleasantness  arising  from  and  associated  with  a  sensation  or 
perception.  We  speak  of  feeling  happy  or  amused  or  sad  as  the 
result  of  some  occurrence  or  experience.  Feelings  of  admiration 
or  of  disgust  are  aroused  by  others.  We  also  speak  of  feeling 
thirsty  or  hungry  or  dizzy,  and  not  incorrectly,  since  the  idea 
expressed  may  include  the  pleasant  or  unpleasant  experiences 
associated  with  these  organic  sensations.  It  is  therefore  not  easy 
to  draw  a  sharp  line  between  feelings  and  organic  sensations  as 
symptoms.  The  symptoms  which  we  may  classify  under  the 
term  "  feeling  "  are  in  reality  experiences  of  pleasantness  or 
unpleasantness  associated  with  organic  sensations  that  are  so 
vaguely  sensed,  and  so  unlocalized,  that  they  fail  to  be  recognized 
as  sensations  at  all.  Such  are  the  feeling  of  general  well-being 
of  the  convalescent  or  the  person  in  buoyant  health,  "  feeling 
fine,"  or  of  vague  general  discomfort,  " feeling  badly";  feelings 
of  lassitude,  of  languor,  of  fatigue,  of  weakness,  of  faintness;  also 
"  feeling  stronger,"  "  feeling  better,"  "  feeling  like  getting  up," 
etc.  These  feelings  of  the  patient,  however  vague  and  unanalyz- 
able,  may  be  nevertheless  symptoms  of  definite  value.  Knowing 
how  the  patient  feels  helps  us  often  to  estimate  correctly  his 
vital  status,  to  picture  to  ourselves  his  position  at  the  moment 
on  the  road  between  health  and  disease.  Feelings  are,  however, 
peculiarly  liable  to  exaggeration  or  the  reverse,  and  they  lack 
the  weight  of  evidence,  as  well  as  the  precision,  of  objective  signs. 
It  is  to  be  remembered  also  that  all  the  subjective  sensations 
and  feelings  of  the  patient  will,  if  above  a  certain  grade  of  inten- 
sity, always  be  accompanied  by  definite  objective  signs.  Thus, 
with  intense  pain  there  will  be,  beside  the  expression  of  the  face, 
the  writhing  movements  and  the  cry  or  moan,  rapid  respiration, 


198  THE  PATIENT 

dilated  pupils,  tense  pulse,  drops  of  perspiration  on  the  skin,  a 
large  amount  of  clear  urine,  nausea,  faintness  and  syncope. 
With  nausea  there  will  be  pallor  of  the  lips  and  later  vomiting, 
and  so  on.  The  patient's  "  feeling  badly  "  will  often  be  found 
to  be  a  reflection  of  a  change  for  the  worse  in  his  temperature, 
pulse,  etc.,  and  may  be  the  first  thing  to  call  the  observer's 
attention  to  the  change.  A  sudden  complaint  of  "  feeling  badly/7 
therefore,  always  calls  for  an  observation  of  the  index  symptoms. 

VIII.  MEASUREMENTS  AND  QUANTITATIVE  ESTIMATIONS 

1.  Measurement  means  the  exact  determination  of  quantity 
or  magnitude  of  the  thing  measured.  It  is  done  by  comparing 
the  magnitude  to  be  measured  with  some  smaller  magnitude  of 
the  same  kind  which  has  been  selected  as  a  standard  unit  for 
the  comparison.  We  say  a  line  is  so  many  inches  long,  a  vessel 
contains  so  many  fluidounces.  Immaterial  forces,  such  as  the 
force  of  gravity  or  the  intensity  of  light  or  heat,  can  be  measured 
as  well  as  material  things.  A  man  weighs  so  many  pounds,  an 
electric  light  bulb  is  of  eight,  sixteen  or  thirty-two  candle-power, 
the  temperature  of  the  air  is  so  many  degrees,  and  so  on. 
Quantitative  determinations  are  of  the  greatest  importance  in 
scientific  study  as  well  as  in  the  daily  business  of  life,  and  there 
are  many  applications  of  this  method  in  medicine.  The  body 
temperature  is  measured  by  the  clinical  thermometer.  Exact 
measurements  are  employed  in  chemical  analyses  in  the  clinical 
laboratory.  The  blood-pressure  is  measured  by  a  special  instru- 
ment. There  are  many  instruments  of  diagnosis  designed  for 
the  purpose  of  making  exact  measurements,  particularly  in  the 
field  of  ophthalmology.  The  tape  line  is  used  to  measure  various 
departures  from  the  normal  in  the  body.  The  amount  of  urine 
is  measured  in  ounces  or  cubic  centimetres,  and  the  same  is  true 
of  the  amount  of  fluid  administered  by  mouth  or  by  rectum  or 
subcutaneously.  Doses  of  medicine  are  measured  by  weight  or 
volume.  Time  measurements  are  employed  in  determining  the 
rate  of  the  pulse  and  respiration. 

In  the  observation  of  symptoms,  however,  we  are  met  at 
once  by  an  apparently  insuperable  difficulty.  Many  of  them  are, 
for  various  reasons,  not  susceptible  of  measurement.  For 
example,  we  cannot  measure  by  any  available  means  the  amount 
of  perspiration,  or  of  discharges  saturating  a  dressing,  or  the 
degree  of  cyanosis  or  of  pallor,  or  the  amount  of  pressure  that 


OBSERVATION  199 

will  produce  pain  in  a  tender  spot.  For  measurements  of  pain 
we  have  no  unit  for  comparison  and  no  way  to  apply  it  if  we  had 
one.  In  the  case  of  pain  and  other  subjective  symptoms,  there 
is  the  added  difficulty  that  they  are  not  within  the  experience  of 
the  observer.  It  is  the  patient  who  experiences  them,  and  the 
observer  therefore  must  depend  on  the  patient's  own  report, 
which  is  often  exaggerated  or  sometimes  the  reverse. 

2.  Quantitative  Estimations:  The  Scale  of  Seven. — As  a 
substitute  for  measurement,  in  the  case  of  these  unmeasurable 
things,  we  may  employ  a  graded  series  of  quantitative  judgments. 
In  regard  to  many  things  that  we  can  observe  but  cannot  measure 
we  are  able  at  once  to  form  a  judgment  of  magnitude  in  three 
grades,  small,  of  moderate  amount,  large;  or  weak,  of  moderate 
strength,  strong;  or  slight,  moderate,  severe;  and  so  on.  We  can 
easily  add  two  more  grades,  one  at  each  end,  as  very  weak  or 
very  strong,  and  finally  we  can  introduce  an  intermediate  grade 
between  weak  and  moderate,  and  another  between  moderate 
and  strong  which  we  may  call  respectively  rather  weak  and  rather 
strong.  We  have  thus  a  scale  of  judgments  of  magnitude  of  seven 
grades,  which  is  as  far  in  the  direction  of  subdivision  as  we  can 
safely  go.  If  the  seven  divisions  be  designated  by  numbers,  the 
even  numbers  (2,  4,  6)  stand  for  the  three  primary  judgments, 
and  the  odd  numbers  (1,  3,  5,  7)  for  the  intermediate  grades. 

Our  scale  then  stands  thus: 

(1)  Very  small.  Very  weak.  Very  slight. 

(2)        Small.  Weak.  Slight. 

(3)  Rather  small.  Rather  weak.  Rather  slight. 

(4)        Medium.  Moderate.  Moderate 

(5)  Rather  larga  Rather  strong.  Rather  severe. 

(6)        Large.  Strong.  Severe 

(7)  Very  large.  Very  strong.  Very  severe. 

In  practice  it  will  be  best  to  make  first  an  offhand  judgment 
on  the  primary  scale  (Weak,  Moderate,  Strong)  and  then,  more 
deliberately,  a  supplementary  judgment,  which  will  be  either  the 
same  as  the  first,  or  one  point  above  or  below,  thus — primary 
judgment,  moderate  (4),  supplementary  judgment,  rather  slight 
(3) .  In  bedside  notes  the  numbers  may  be  used,  out  in  the  perma- 
nent record  the  descriptive  words  should  always  be  written  out. 
Thus  (4),  (3)  will  read,  "  moderate,  or  rather  slight  "  as  applied 
to  whatever  is  being  estimated. 

These  quantitative  judgments,  of  course,  have  no  claim  to 
rank  as  exact  measurements,  and  there  will  be  rather  wide  varia- 


200  THE  PATIENT 

tions  in  the  judgments  of  different  individuals.  In  regard  to 
subjective  symptoms,  the  estimate  must  be  based  on  the  patient's 
own  report,  but  this  can  often  be  supplemented  by  the  observable 
manifestations  of  the  symptom.  In  the  case  of  pain,  for  example, 
rather  severe  pain  (5)  may  be  taken  to  be  that  which  will  be 
clearly  evident  in  the  expression  of  the  face;  severe  pain  (6)  will 
show  in  the  voice,  or  by  cry  or  moan;  while  very  severe  pain  (7) 
will  be  manifested  by  such  other  signs  of  pain  as  pallor,  quickened 
respiration,  moist  skin,  etc.,  so  that  even  here  we  do  not  have 
to  depend  on  the  patient's  report  solely,  except  in  the  case  of 
the  slight  and  moderate  degrees  which  are  usually  of  less  signifi- 
cance. These  objective  signs  should  always  be  recorded  as 
observed. 

When  a  quantity  of  fluid  is  to  be  estimated,  it  may  be  done 
by  a  rough  guess  at  the  amount,  as  for  instance,  "  about  two 
drachms  "  or  "  about  four  ounces."  When  this  is  done  the 
abbreviation  (est.)  should  be  added  to  indicate  that  the  amount 
is  estimated  and  not  measured.  The  degree  of  accuracy  required 
in  measurement,  or  the  limit  of  permissible  error,  varies  according 
to  the  object  in  view.  The  weight  of  a  dose  of  atropine  should  be 
correct  within  a  thousandth  of  a  grain,  while  a  dose  of  Epsom 
salts  may  vary  a  number  of  grains  without  harm.  The  amount  of 
urine  frequently  requires  to  be  measured  with  accuracy,  but  the 
amount  of  vomited  material  need  only  be  roughly  estimated. 

The  measurements  to  be  regularly  made  by  the  nurse  include 
the  temperature,  rate  per  minute  of  the  pulse  and  respiration; 
the  quantity  of  urine  voided  and  of  liquid  taken;  the  amount  of 
salt  solution  given,  under  the  skin  or  by  rectum;  enemata  and 
medicines. 

3.  The  record  made  by  the  nurse  should  be  (1)  brief,  (2)  a 
simple  statement  of  the  facts  recognized  by  sight,  hearing,  or 
touch,  without  an  expression  of  opinion  as  to  their  cause,  (3)  ac- 
curate, (4)  clear.  Vague  statements  should  be  avoided.  Each 
observation  should  be  recorded  by  itself,  and  the  time  of  its 
occurrence  stated. 


CHAPTER  XV 

MEASURES   FOR   THE   COMFORT   AND   WELL-BEING 
OF  THE  PATIENT 

A  LARGE  part  of  the  work  of  the  nurse  is  carried  out  under 
either  standing  or  special  orders  written  down  in  the  order  book 
by  the  surgeon  or  physician  in  charge. of  the  case,  and  her  respon- 
sibility is  then  limited  to  obedience  and  the  proper  exercise  of 
the  technical  knowledge  and  skill  acquired  in  the  practice  of  her 
profession.  The  doctor  is  the  one  who  is  responsible  for  the 
treatment  of  the  disease  or  affection  which  brings  the  patient 
under  his  care.  It  is  his  part  to  determine  what  remedial  meas- 
ures shall  be  employed,  and  it  is  the  part  of  the  nurse  to  carry 
out,  under  his  orders,  such  of  them  as  come  within  her  province. 

There  is,  however,  a  part  of  the  nurse's  work  in  which  she  is 
left  to  act  largely  on  her  own  responsibility,  without  general  or 
special  written  orders,  in  applying  the  knowledge  and  skill  she 
has  acquired  in  the  course  of  her  training  with  regard  to  the 
proper  care  of  the  sick.  This  field  of  the  work  of  the  nurse  con- 
cerns the  general  well-being  and  comfort  of  the  patient.  It  is, 
from  the  patient's  point  of  view,  the  most  important  part  of 
nursing,  and  it  often  calls  for  the  highest  degree  of  discretion  and 
good  judgment  on  the  part  of  the  nurse.  Pain  and  suffering, 
both  physical  and  mental,  are  inseparable  from  disease  and  injury, 
and  in  their  alleviation  efficient  nursing  plays  the  principal  part. 

It  is  assumed  that  the  nurse  is  instructed  in  regard  to  the 
general  hygiene  of  the  sick-room,  the  care  of  the  bed,  the  bath, 
adequate  ventilation  and  the  flushing  of  the  room  with  fresh  air 
at  suitable  intervals,  the  proper  arrangement  of  light,  the  serving 
of  food  in  attractive  form,  and  prompt  attention  to  the  essential 
needs  of  the  patient,  the  prevention  and  care  of  bed-sores,  and 
the  alleviation  of  the  many  small  discomforts  incident  to  every 
illness.  We  shall  consider  in  this  chapter  some  points  in  surgical 
nursing  to  which  insufficient  attention  is  often  given  by  the 
nurse,  and  it  must  be  said  by  the  surgeon  as  well,  resulting  in 
much  unnecessary  discomfort  to  the  patient,  and  sometimes  in 
lasting  injury. 

201 


202  THE  PATIENT 

I.  POSITION  IN  BED 

The  dorsal  position,  prone  on  the  back,  is  the  position  in 
which  the  patient  is  usually  placed  in  bed  immediately  after 
operation.  It  is  the  natural  position  of  complete  relaxation  and 
exhaustion  and  can  be  maintained  longer  than  any  other  without 
discomfort.  There  are,  however,  grave  objections  to  prolonged 
lying  on  the  back.  It  is  a  contributing  cause  of  hypostatic 
pneumonia  and  of  cystitis,  and  a  direct  cause  of  bed-sores. 
Change  of  position  by  turning  the  patient  on  the  side,  if  necessary 
with  supporting  pillows  under  shoulder  and  hips,  should  be 
encouraged  and  even  insisted  on  whenever  possible.  There  are 
only  a  few  conditions  in  which  a  continued  dorsal  position  is 
unavoidable,  and  abdominal  operations  are  not  among  them, 
in  spite  of  the  common  practice  of  keeping  these  patients  on  the 
back.  The  methods  of  treating  fractures  of  the  thigh  and  hip, 
which  are  still  very  frequently  employed,  compel  the  patient 
to  lie  on  his  back  for  many  weeks,  but  even  here  restful  changes 
of  position  can  be  managed  without  harm,  if  proper  discretion 
and  care  are  used ;  indeed,  the  patient  will  soon  learn  to  ease  him- 
self by  shifting  his  body  about,  and  may  have  to  be  cautioned 
against  too  free  movements.  After  abdominal  operations  a 
pillow  placed  under  the  knees  so  that  the  thighs  are  slightly 
flexed  adds  greatly  to  the  comfort  of  the  patient.  The  head  and 
usually  the  shoulders  may  be  supported  with  pillows  after  all 
operations  as  soon  as  the  patient  finds  them  comfortable. 

The  covering  should  be  warm  and  light  and  not  too  smoothly 
and  tightly  tucked  in  around  a  weak  and  helpless  patient.  One 
point  in  this  connection  needs  particular  emphasis.  Patients 
who  are  bed-ridden  for  a  long  time  are  very  prone  to  develop 
foot-drop,  the  feet  becoming  fixed  in  an  extended  position  by 
the  contraction  of  the  calf  muscles,  a  condition  that  may  take 
weeks  or  even  months  to  overcome  after  convalescence  is  estab- 
lished, the  patient  meantime  being  seriously  crippled.  This  an- 
noying complication  is  wholly  preventable  and  the  principal 
cause  of  it  is  the  careful  smoothing  and  tucking  in  of  the  lower 
bed  coverings,  which  adds  so  much  to  the  neat  appearance  of 
the  ward  while  at  the  same  time  it  fixes  the  weakened  patient's 
feet  in  the  extended  position  as  if  with  immovable  splints.  In 
all  cases,  whether  surgical  or  medical,  where  the  patient  is  con- 
fined to  the  bed  for  a  long  time,  the  bedclothes  over  the  feet 
should  be  supported  by  a  cradle,  or  at  least  left  loose,  and  careful 
attention  should  be  given  to  the  position  of  the  feet. 


COMFORT  AND  WELL-BEING  OF  PATIENT  203 

II.  APPLICATION  OF  HEAT  AND  COLD 

Applications  of  heat  and  cold  by  means  of  hot-water  bags  or 
bottles,  ice-bags,  or  of  cloths  wrung  out  of  hot  or  cold  water,  are 
measures  within  the  discretion  of  the  nurse.  Keeping  the  patient 
warm  with  water-bottles  and  blankets  is  a  routine  procedure 
after  all  severe  operations  followed  by  shock,  but  is  one  that  is 
liable  to  grave  abuse.  To  make  clear  why  this  is  so,  and  what  is 
the  real  object  to  be  attained,  an  explanation  is  necessary.  The 
so-called  warm-blooded  animals,  including  birds  and  mammals 
(of  which  latter  class  man  and  the  four-footed  domestic  animals 
are  examples),  possess  a  heat-regulating  mechanism,  under  the 
control  of  the  nervous  system,  which  maintains  a  balance  between 
the  production  of  heat  within  the  body  by  the  chemical  activities 
of  the  cells,  and  the  loss  of  heat  from  the  surface,  through  radia- 
tion and  evaporation,  so  that  the  actual  temperature  of  the  body 
is  kept  at  a  nearly  constant  level.  Thus  the  temperature  of  the 
circulating  blood  is  independent  of  surrounding  conditions.  It 
is  the  same  in  winter  as  in  summer,  in  the  arctic  as  in  the  tropical 
regions.  In  the  case  of  the  cold-blooded  animals  this  is  not  so; 
their  body  temperature  varies  with  their  surroundings.  The 
temperature  of  reptiles  and  fishes  is  at  all  times  the  same  within 
a  few  degrees  as  that  of  the  water  or  air  within  which  they  live. 
This  is  their  normal  condition,  to  which  they  are  adapted,  and 
they  are  able  to  withstand  very  great  changes  in  body  tempera- 
ture without  ill  effect.  Some  of  them  can  survive  chilling  even 
to  the  freezing  point.  Warm-blooded  animals  are  therefore 
called  homoeothermic,  that  is,  with  unvarying  heat;  while  cold- 
blooded animals  are  poecilothermic,  that  is,  with  changing  heat. 
Warm-blooded  animals  are  able  to  endure  only  a  limited  change 
of  temperature.  Cases  are  on  record  of  persons  exposed  to 
extreme  cold,  without  sufficient  protection  to  maintain  the  body 
heat,  who  have  recovered  after  the  rectal  temperature  has  fallen 
to  76°  F.,  but  when  the  rectal  temperature  has  fallen  to  70°  F. 
death  invariably  ensues.  Thus  when  men  "  freeze  to  death," 
they  die  before  the  circulating  blood  has  reached  what  is  regarded 
as  a  comfortable  room  temperature.  Now  under  certain  condi- 
tions the  human  body  becomes  in  a  sense  pcecilothermic,  that 
is,  it  tends  to  assume  the  temperature  of  the  surrounding  medium, 
although  it  does  not  become  adapted  to  sustain  such  changes 
without  harm.  Prematurely  born  infants  are  in  this  condition, 
and  those  born  at  term  are  partially  so  for  a  time.  But  the  condi- 
tion of  pcecilothermism  of  particular  interest  to  us  is  a  surgical 


204  THE  PATIENT 

one.  In  surgical  shock  and  in  severe  hemorrhage  the  heat-con- 
trolling mechanism  fails.  The  temperature  tends  to  fall  to  that 
of  the  surrounding  medium,  and  such  patients  may  "  freeze  to 
death"  through  exposure  to  ordinary  room  temperature.  In 
these  conditions  the  loss  of  heat  must  be  prevented  by  proper 
coverings  and  the  surrounding  temperature  maintained  at  or  a 
little  above  the  normal  level.  The  water-bottles  surrounding 
the  patient  therefore  should  be  warm  but  not  hot,  since  the  object 
is,  not  to  raise  the  patient's  temperature,  but  to  prevent  loss  of 
heat  from  the  surface.  An  additional  reason  for  having  the  water 
in  the  bottles  at  a  moderate  temperature  is  the  great  liability 
of  the  unconscious  patient  to  be  badly  burned  by  contact  with 
a  bottle  that  is  even  moderately  hot.  This  unfortunate  accident 
has  occurred,  at  one  time  or  another,  in  almost  every  hospital. 
It  results  not  only  in  great  and  prolonged  suffering  to  the  patient, 
but  often  in  expensive  litigation  against  the  hospital  authorities. 
The  accident  is  inexcusable  because  it  is  so  easily  preventable. 
The  usual  teaching  is  that  the  bottles  should  be  placed  at  a 
distance  from  the  patient,  with  layers  of  blanket  between  in 
order  to  prevent  burning,  but  this  is  not  the  proper  remedy.  The 
patient,  tossing  about,  is  sure  to  come  in  contact  with  the  bottles 
in  spite  of  this  precaution.  The  temperature  of  the  water  in  the 
bottles  must  be  low  enough  so  that  they  cannot  possibly  burn. 

Sloughs  may  also  be  caused  by  the  ice-bag  if  it  is  kept  too 
closely  or  too  long  in  contact  with  the  skin.  Several  layers  of 
gauze  should  always  be  placed  between  the  bag  and  the  surface 
of  the  body,  and  the  bag  itself  should  be  removed  for  a  short 
time  at  least  every  hour  or  two. 

Hot  wet  dressings  form  the  best  local  treatment  for  all  forms 
of  septic  infection.  When  frequent  changes  of  such  dressings 
are  desirable  this  duty  may  be  entrusted  to  the  nurse.  Local 
heat  is  employed  also  for  the  relief  of  pain,  and  this  is  almost 
the  sole  indication  for  the  application  of  cold. 

III.  MEASURES  FOR  THE  RELIEF  OF  PAIN 

We  have  always  at  hand  a  method  of  relieving  pain,  certain, 
easy,  and  practically  instantaneous;  but  this  easy  method  carries 
with  it,  unfortunately,  an  almost  equal  facility  for  doing  incalcu- 
lable harm.  The  first  principle,  therefore,  in  the  treatment  of 
pain  is  that  morphia,  the  great  anodyne,  is  to  be  resorted  to 
only  when  absolutely  necessary.  The  nurse  is  not  privileged 


COMFORT  AND  WELL-BEING  OF  PATIENT  205 

fco  administer  it  without  orders  from  the  physician,  but  such 
orders  are  frequently  provisional,  so  that  the  immediate  respon- 
sibility for  deciding  when  it  shall  be  given  rests  often  upon  the 
nurse.  No  hard-and-fast  rules  for  her  guidance  can  be  laid  down, 
but  a  few  suggestions  of  a  general  character  may  be  made.  When 
morphia  is  positively  ordered  the  nurse  has  no  choice  but  to 
administer  it:  she  may,  however,  interpret  as  provisional  an 
order  not  so  phrased,  if  there  is  a  reasonable  presumption  that 
it  was  intended  as  such.  She  may  accept  as  final  the  patient's 
refusal  to  take  it.  The  nurse  should  never  insist  on  the  patient's 
taking  morphia  against  his  will,  except  perhaps  in  the  case  of  the 
routine  pre-operative  hypodermic.  When  morphia  has  been 
provisionally  ordered  it  should  usually  be  withheld  for  all  degrees 
of  pain  up  to  and  including  moderate  pain  (number  4  in  the 
scale  of  seven).  In  severe  and  very  severe  pain  (6  and  7)  it 
should  be  given  at  once  unless  the  pain  is  tending  to  diminish, 
in  which  case  it  may  be  delayed  for  a  time  while  other  simple 
means  of  relief  are  tried.  Number  5  in  the  scale  (rather  severe 
pain)  is  the  dividing  line  where  the  nurse  must  act  according  to 
her  best  judgment.  The  patient  should  be  told  that  he  is  better 
off  without  morphia  if  he  can  endure  the  pain,  and  he  should  be 
encouraged  in  every  way  in  a  voluntary  refusal  to  take  it.  Of 
course  it  is  exactly  in  the  cases  where  the  giving  of  morphia  is 
most  undesirable  that  the  patient's  own  report  as  to  the  degree 
of  pain  from  which  he  is  suffering  is  least  reliable.  It  is  particu- 
larly against  repeated  daily  doses  of  morphia  that  the  patient 
must  be  guarded  by  every  possible  means.  In  the  last  stages  of  a 
hopeless  and  painful  disease  most  of  us  feel  that  these  rigid  rules 
may  properly  be  relaxed.  The  other  less  dangerous  and  also  less 
efficient  anodynes  may  be  given  with  more  freedom,  but  even 
with  these  great  discretion  should  be  used. 

The  simple  means  for  the  relief  of  pain  vary  with  the  location, 
character,  and  cause  of  the  pain.  Inflammatory  pain  is  always 
associated  with  tenderness  on  pressure  and,  if  the  superficial 
tissues  are  involved,  with  redness  of  the  skin  and  swelling.  The 
application  of  cold,  elevation  of  the  part  when  possible,  and 
removal  of  pressure  help  to  give  relief.  The  first  principle  in  the 
treatment  of  pain  from  trauma  is  rest;  that  is,  keeping  the  part 
still.  Cold  and  elevation  also  assist  here.  Neuralgic  pains  are 
usually  aggravated  by  cold:  heat  and  stimulating  local  applica- 
tions (such  as  cause  a  burning  sensation  and  redness  of  the  skin) 


206  THE  PATIENT 

help  them.  Cramp  pains  in  the  muscles  are  relieved  by  rubbing, 
pressure  and  heat.  Aching  in  the  back  and  limbs  caused  by 
strain  from  lying  in  the  same  position  for  a  long  time  is  a  frequent 
source  of  great  discomfort  to  patients.  Even  very  slight  changes 
of  position  from  time  to  time  give  the  greatest  relief.  Smarting 
pain  from  slight  abrasions  of  the  skin,  as  at  the  sharp  edge  of  a 
bandage,  are  treated  by  removal  of  the  cause  of  irritation  and 
protection  with  a  dry  powder  or  a  soothing  ointment. 

Burning  and  smarting  pain,  and  itching,  due  to  the  effect  on 
the  skin  of  irritating  secretions,  may  be  relieved  by  cleanliness 
and  drying  powders,  or  by  simple  alkaline  lotions,  such  as  carbon- 
ate of  soda  (1  per  cent,  solution),  or  oxide  and  precipitated  car- 
bonate of  zinc  (two  drachms  of  each  to  four  ounces  of  glycerine 
and  rose  water).  The  most  aggravated  cases  of  this  form  of 
irritation  occur  when  an  intestinal  fistula  has  formed  involving 
the  upper  part  of  the  small  intestine.  The  active  digestive  secre- 
tions from  this  portion  of  the  digestive  tract  play  dreadful  havoc 
with  the  skin  when  they  are  poured  out  constantly  upon  the 
surface  of  the  abdomen,  and  the  resulting  suffering  of  the  patient 
is  constant  and  almost  unendurable.  The  condition  is  rare,  but 
the  suffering  is  very  difficult  to  control  when  it  occurs.  Fecal 
matter  soiling  the  surface  from  fistulse  communicating  with  the 
lower  part  of  the  intestine  causes  little  or  no  irritation  of  the  skin. 

Pain  and  discomfort  from  abdominal  distention  with  gas  is  a 
common  occurrence  after  operations  in  which  the  peritoneum 
has  been  incised  and  sutured.  It  lasts  for  two  or  three  days  or 
until  the  bowels  have  moved  freely.  No  sure  means  of  preventing 
it  has  been  discovered,  or,  at  any  rate,  none  is  generally  known  and 
practised.  Hot  fomentations,  enemata  and  the  passage  of  the 
rectal  tube  give  some  measure  of  relief.  Morphia,  of  course,  con- 
trols the  pain  but  tends  to  aggravate  the  distention.  Pain  from 
the  operative  wound  itself  is  not,  as  a  rule,  either  severe  or  lasting. 
Provisional  orders  for  hypodermics  of  morphia  to  relieve  it  are 
commonly  given.  There  is  undoubtedly  a  tendency  towards  too 
great  laxity  in  this  respect  both  on  the  part  of  the  surgeon  and 
the  nurse,  and  the  suggestions  already  given  for  the  carrying  out 
of  such  provisional  orders  should  be  carefully  observed.  A  num- 
ber of  other  painful  conditions  may  be  met  with,  following  opera- 
tions. Practically  all  of  them  arise  from  some  form  of  trauma 
suffered  by  the  patient  on  the  table.  The  backache  already 
referred  to  is  common.  It  is  difficult  to  relieve  and  it  frequently 


COMFORT  AND  WELL-BEING  OF  PATIENT  207 

lasts  for  many  days.  Every  effort  should  be  made  to  prevent 
its  occurrence.  Sore  tongue,  sore  throat,  and  sore  jaw  result 
from  the  efforts  of  the  anaesthetist  to  overcome  obstructed  breath- 
ing. A  too  tight  or  improperly  adjusted  bandage  may  give  rise 
to  much  discomfort  or  even  pain.  A  distended  bladder  from 
retention  of  urine  is  a  common  source  of  discomfort  after  opera- 
tion. Every  effort  to  avoid  the  use  of  the  catheter  must  be  made, 
but  it  is  unsafe  to  delay  more  than  twelve  to  sixteen  hours  at  the 
most.  Too  great  emphasis  cannot  be  laid  upon  the  necessity  for 
strict  asepsis  in  this  procedure.  The  bladder  is  extremely  sus- 
ceptible to  infection  and  the  resulting  cystitis  is  a  serious  compli- 
cation. 

Finally,  every  effort  should  be  made  to  assist  the  patient  in 
maintaining  a  healthy  mental  attitude  towards  pain,  particularly 
in  the  long- continued  chronic  cases  where  the  normal  mental  con- 
trol is  apt  to  be  severely  tried.  Cheerfulness  and  a  hopeful  out- 
look help  greatly  to  lighten  the  acuteness  of  physical  suffering; 
laughter  is  a  great  anodyne  for  the  slighter  grades  of  pain.  The 
sole  function  and  business  of  pain  is  to  seize  upon  and  hold  the 
attention,  and  if  it  can  be  prevented  from  doing  this  by  any  means 
at  all  its  power  is  gone.  In  its  higher  degrees  of  intensity  the 
demand  of  pain  upon  the  attention  is  imperative  and  cannot  be 
denied,  but  for  the  slighter  grades  any  object  of  interest  that  can 
occupy  the  mind  is  a  potent  antagonist.  Whenever  the  attention 
becomes  fixed  on  something  else  pain,  if  present,  rapidly  falls  in 
the  scale  of  intensity  and  may  even  vanish  momentarily  from 
consciousness  like  a  dissolving  view.  It  is  a  commonplace  obser- 
vation that  the  patient  feels  better  during  the  doctor's  visit,  not, 
of  course,  because  of  any  soothing  virtue  in  his  presence,  but 
because  the  patient's  attention  is  attracted  strongly  away  from 
his  own  sensations  of  pain  or  discomfort.  On  the  other  hand, 
moderate  pain  seems  to  become  more  severe  if  the  mind  dwells 
constantly  upon  it,  and  a  morbid  mental  outlook  tends  to  bring 
into  the  focus  of  consciousness  all  those  numberless,  slight, 
fugitive  and  meaningless  pains  to  which  every  one  is  subject  but 
which  pass  unnoticed  in  health. 

IV.  WATER  AND  FOOD 

1.  The  need  for  water  is  the  most  imperative  requirement  of 
all  living  things,  and  the  distress  arising  from  prolonged  depriva- 
tion of  it  is  probably  not  surpassed  by  any  other  form  of  suffering. 


208  THE  PATIENT 

One  of  the  most  unpleasant  memories  that  patients  who  have 
had  an  operation  performed  under  ether  anaesthesia  carry  away 
with  them  is  that  of  discomfort  from  thirst.  For  this  reason, 
and  also  because  of  the  great  value  of  water  as  a  remedy  in  certain 
conditions,  it  is  important  that  the  principles  involved  in  the 
administration  of  water  in  surgical  cases  should  be  very  clearly 
laid  down. 

In  the  first  place,  water  should  be  administered  freely  in  all 
surgical  cases  and  at  all  times.  There  are,  it  is  true,  a  few  condi- 
tions, to  be  enumerated  below,  in  which  water  by  mouth  must 
be  withheld  for  a  time,  but  this  does  not  mean  that  water  is  not 
to  be  given  at  all;  on  the  contrary,  when  it  cannot  be  taken  by 
mouth  it  should  be  given  by  one  of  the  other  two  possible  methods 
of  administering  it;  namely,  by  direct  injection  into  the  tissues, 
usually  under  the  skin,  or  by  the  rectum.  Either  of  these  methods 
is  a  more  direct  way  of  introducing  water  into  the  circulation 
than  giving  it  by  mouth.  There  is  very  little  absorption  of  water 
through  the  walls  of  the  stomach  or  small  intestine.  It  is  ab- 
sorbed rapidly  in  the  colon  and  rectum.  When  injected  under 
the  skin  it  passes  almost  directly  into  the  circulation.  Water 
may  be  given  by  rectum  in  one  of  two  ways :  either  by  the  con- 
tinuous drop  method  or  by  the  injection  of  from  eight  to  twelve 
ounces  every  two  to  four  hours.  Either  plain  water  or  normal 
physiological  salt  solution  may  be  used.  The  latter  must  always 
be  employed  when  water  is  to  be  given  by  subcutaneous  injec- 
tion: in  this  case  it  must,  of  course,  be  absolutely  sterile. 

In  all  forms  of  infection  the  administration  of  water  in  large 
amount  is  by  far  the  most  important  part  of  the  internal  treat- 
ment. It  aids  in  the  rapid  elimination  of  the  toxins  from  the 
blood  through  the  excretions.  In  cases  of  severe  sepsis  the  patient 
should  be  made  to  take  at  least  a  half  glass  of  water  every  half 
hour  when  awake.  It  is  desirable  that  water  should  be  taken 
abundantly  for  several  days  before  an  operation,  and  also  after- 
wards, as  soon  as  the  stomach  will  retain  it.  Rectal  injections 
of  water  should  be  resorted  to  after  all  operations  when  vomiting 
continues  for  more  than  a  few  hours. 

Thirst  is  a  distressing  symptom  immediately  after  almost 
every  operation  when  a  general  anaesthetic  has  been  used.  There 
are  several  causes  for  this. 

In  the  first  place,  the  preliminary  hypodermic  of  morphia 
and  atropia  usually  given  tends  to  check  the  secretions  in  the 


COMFORT  AND  WELL-BEING  OF  PATIENT  209 

mouth  and  throat,  leaving  the  mucous  membrane  abnormally 
dry,  and  the  anaesthetic  itself  aggravates  this  condition.  There 
is  also  a  considerable  loss  of  body  fluids  at  every  operation, 
resulting  from  the  preliminary  purging,  from  vomiting,  from 
perspiration  and  from  hemorrhage.  From  these  causes  many 
patients  after  operation  suffer  acutely  from  thirst,  and  this  is 
increased  by  the  common  practice  of  withholding  water  alto- 
gether, or  giving  it  very  sparingly,  for  the  first  twelve  hours  or 
until  the  stomach  will  retain  it.  When  water  is  withheld  because 
of  continued  nausea  and  vomiting,  the  administration  of  saline 
solution  or  plain  water  by  the  rectal  route  helps  greatly  to  relieve 
thirst  by  supplying  the  body  with  the  necessary  amount  of  fluid. 
Frequent  rinsing  of  the  mouth  with  water  adds  to  the  patient's 
comfort,  by  relieving  the  dryness  of  the  mucous  membrane.  In 
the  presence  of  nausea  hot  water  is  better  borne  by  the  stomach 
than  cold.  It  is  more  palatable  when  given  in  the  form  of  weak 
tea.  Sipping  cold  water  in  small  quantities  is  not  to  be  recom- 
mended. It  does  not  satisfy  the  patient's  thirst,  and  is  quite  as 
certain  to  induce  vomiting  as  when  given  in  larger  amount. 
After  operations  of  such  a  nature  that  the  act  of  vomiting  in 
itself  does  no  particular  harm  the  restrictions  against  giving 
water  need  not  be  so  rigidly  observed.  The  washing  out  of  the 
stomach  which  ensues  is  rather  an  advantage  than  otherwise, 
tending  to  hasten  the  return  of  that  organ  to  its  normal  condi- 
tion, by  relieving  it  of  a  load  of  ether-saturated  secretions  that 
have  accumulated  during  the  operation. 

The  surgical  conditions  in  which  water  by  mouth  must  be 
withheld  are  three,  or  at  most  four,  in  number :  (1)  after  operation 
of  such  a  character  that  the  act  of  vomiting  is  apt  to  do  violence 
to  the  wounded  tissues,  as  for  example  operations  on  any  of  the 
organs  within  the  abdomen  and  particularly  upon  the  stomach 
itself;  (2)  in  cases  of  acute  intestinal  obstruction,  and  (3)  in 
general  peritonitis.  In  the  two  latter  conditions  it  is  useless  to 
give  water  by  mouth,  since  it  cannot  be  passed  on  to  that  part 
of  the  intestine  where  it  will  be  absorbed.  Systematic  stomach 
washing  and,  of  course,  appropriate  operative  interference  are 
indicated  in  these  cases.  We  may  include  in  a  fourth  group  all 
other  cases  in  which  from  whatever  cause  the  stomach  immedi- 
ately rejects  whatever  is  put  into  it. 

2.  The  principles  governing  the  feeding  of  surgical  patients 
may  be  briefly  stated  in  very  simple  terms.  The  disturbance  of 
14 


210  THE  PATIENT 

digestion  caused  by  the  anaesthetic  makes  it  necessary  to  adminis- 
ter nourishment  very  sparingly  until  the  stomach  has  recovered 
its  tone.  The  rule  is  that,  in  uncomplicated  cases,  after  the 
patient's  bowels  have  moved,  usually  on  the  third  day,  almost 
any  wholesome  food  may  be  given  in  reasonable  quantities.,  It 
is  unnecessary  to  restrict  the  patient  to  a  liquid  diet  through  the 
period  of  healing.  When  fever  is  present  the  rules  that  govern 
feeding  in  medical  cases  with  fever  apply.  After  operations  upon 
the  stomach  or  intestines  nothing  is  to  be  given  by  mouth  for  the 
first  twenty-four  hours.  On  the  second  day  albumen  water  and 
water  or  weak  tea  may  be  given  in  small  quantities  at  a  time 
every  two  or  three  hours.  On  the  third  day  broths  and  light 
gruels  may  be  given.  The  amount  and  variety  of  food  are  increased 
gradually  until  at  the  end  of  a  week  a  fairly  full  diet  is  attained. 

V.  ATTENTION  TO  BANDAGES  AND  DRESSINGS 

The  nurse  should  regularly  observe  the  dressings  over  the 
wound  to  detect  staining  with  blood  during  the  first  few  hours, 
and  later  for  soiling  with  discharges  from  the  wound,  or  with 
urine  or  fecal  matter.  Concealed  dressings,  such  as  packs  of 
gauze  in  the  uterus  or  vagina,  for  example,  may  sometimes  be 
overlooked.  The  nurse  should  consider  that  she  shares  with  the 
surgeon,  in  some  measure  at  least,  the  responsibility  for  seeing 
that  these  are  removed  at  the  proper  time,  and  should  call  his 
attention  to  them  if  he  has  allowed  them  to  remain  more  than 
three  or  four  days. 

Pressure  from  bandages  too  tightly  applied  is  a  not  infrequent 
source  of  discomfort  and  even  pain  to  the  patient.  A  sharp  fold 
cutting  into  the  skin  at  the  edge  of  the  bandage  may  be  trimmed 
away  by  the  nurse.  She  cannot,  of  course,  except  in  emergency, 
take  the  responsibility  of  cutting  the  bandage  to  any  great 
extent,  but  she  should  report  to  the  surgeon  any  complaints  the 
patient  may  have  made.  Bandages  around  the  chest,  applied 
while  the  patient  is  relaxed  and  unconscious  on  the  table,  are 
particularly  apt  to  be  too  tight.  The  resulting  restriction  to 
chest  expansion  in  the  act  of  breathing,  at  first  felt  as  a  minor 
discomfort,  becomes  after  some  hours  a  positive  torture.  As  the 
nurse  may  some  time  be  entrusted  with  the  duty  of  relieving  this 
condition,  it  is  well  for  her  to  know  how  it  should  be  done.  At 
the  side  of  the  patient's  body  farthest  removed  from  the  wound 
the  bandage  is  cut  with  the  scissors,  beginning  at  one  edge  and 


COMFORT  AND  WELL-BEING  OF  PATIENT  211 

extending  two-thirds  of  the  way  across  towards  the  opposite  edge. 
Four  inches  away  from  this  first  cut  a  second  cut  is  made,  begin- 
ning at  the  opposite  edge  and  extending  two-thirds  of  the  way 
across.  Both  cuts  include  all  the  thickness  of  the  bandages  down 
to  the  skin.  These  two  cuts  overlap  each  other  in  the  middle 
third  of  the  width  of  the  bandage,  lying  parallel  and  four  inches 
apart.  The  bandage  then  opens  up  like  a  lazy  tongs  gate,  allow- 
ing free  chest  expansion  but  not  disturbing  in  the  least  the 
dressings  over  the  wound.  A  strip  of  adhesive  plaster  or  a  small 
piece  of  bandage  pinned  across  each  gap  at  the  upper  and  lower 
edge  then  makes  all  secure. 

When  splints  or  a  rigid  plaster-of-Paris  bandage  have  been 
applied  to  a  limb,  pressure  over  some  concealed  point  may  give 
rise  to  severe  sloughing  if  neglected.  Every  complaint  of  the 
patient  as  to  pain  or  discomfort  within  a  rigid  splint  or  bandage, 
no  matter  how  trivial,  should  be  given  careful  attention  and 
should  be  reported  without  fail  to  the  surgeon.  If  such  a  rigid 
dressing  has  been  applied  to  a  limb  without  including  the  hand 
or  foot,  as  the  case  may  be;  and  if  at  any  time  the  hand  or  foot 
becomes  blue  and  markedly  swollen  or  numb,  then  the  bandage 
must  be  cut  through  its  whole  length  and  thickness  (but  not 
otherwise  disturbed)  so  as  to  allow  the  circulation  of  the  part  to 
be  restored,  and  if  the  surgeon  is  not  accessible  within  a  reason- 
able time  the  nurse  must  assume  the  full  responsibility  of  doing 
this.  Slipping  or  displacement  of  a  bandage  from  being  too 
loosely  applied  is  a  less  common  occurrence,  but  one  that  must 
be  borne  in  mind  and,  of  course,  attended  to  and  reported  when- 
ever it  occurs. 

VI.  PRECAUTIONS  IN  ACUTELY  INFECTED  CASES 

The  precautions  to  be  taken  in  acutely  infected  cases  (par- 
ticularly those  infected  with  the  gonococcus)  naturally  divide 
themselves  into  three  categories:  those  for  the  protection  of  the 
patient  infected;  those  for  the  protection  of  the  other  patients 
or  the  household  of  the  infected  person;  and  those  for  the  pro- 
tection of  the  nurse. 

1.  The  Patient. — All  care  should  be  taken  to  prevent  the 
transference  of  the  infection  from  its  original  site  to  any  other 
field.  If,  therefore,  the  vulva  and'  vagina  are  acutely  infected, 
great  care  should  be  taken  to  prevent  the  further  infection  of 
the  urethra,  or  the  carrying  of  the  infection  to  the  eyes.  The 


212  THE  PATIENT 

former  is  attained  by  the  avoidance  of  catheterization  and  the 
careful  and  persistent  cleansing  of  the  parts.  The  second  danger 
is  avoided  by  explanation  to  the  patient  of  the  great  danger  to 
her  sight  from  any  transfer  of  the  infection  by  hands  or  clothes 
to  the  eyes  and  by  careful  oversight  to  prevent  the  use  of  any 
cloths  or  implements  by  the  patient  that  might  by  any  chance 
have  come  into  contact  with  the  infectious  matter. 

2.  The  Household  or  Other  Patients. — To  prevent  the  spread 
of  infection  to  others,  the  patient  should  be  subject  to  what 
would  amount  to  a  mild  isolation.     Great  care  should  also  be 
taken  that  others  do  not  use  the  same  towels,  wash  cloths,  or 
other  toilet  articles,  without  careful  preliminary  sterilization. 

3.  The  Nurse. — For  self-protection,  the  nurse  should  take 
great  care  in  her  treatments  to  the  patient;  in  her  handling  of 
infected  dressings;  and  in  her  cleansing  of  her  hands  after  each 
dressing. 

As  an  additional  precaution,  no  nurse  who  is  attending  such 
a  case  (this  pertaining  particularly  in  those  hospitals  where  the 
services  are  not  carefully  segregated)  should  be  permitted  to 
attend  obstetrical  patients. 


CHAPTER  XVI 

ROUTINE  NURSING   IN  OPERATIVE  CASES 
I.  PREPARATION  OF  THE  PATIENT  FOR  OPERATION 

THE  preparation  of  the  patient  for  operation,  while  apparently 
a  very  simple  procedure,  requires  the  same  forethought  and  care- 
ful attention  to  detail  that  characterizes  any  of  the  other  pro- 
cedures of  surgical  and  gynaecological  nursing.  While  the  various 
steps  are  more  or  less  routine  in  character  (and  may,  at  times, 
appear  somewhat  senselessly  so),  a  reasonable  and  logical  cause 
may  be  found  at  the  foundation  of  each  procedure,  and  (this 
reason  once  understood)  the  conscientious  nurse  will  appreciate 
the  importance  of  adhering  as  strictly  as  possible  to  the  minutiae 
of  preparation. 

A.  Bowel  Function. — As,  unfortunately,  a  large  proportion  of 
our  patients,  particularly  in  gynaecological  work,  are  inclined  to 
a  more  or  less  obstinate  degree  of  constipation,  the  necessity  of 
a  thoroughly  evacuated  intestinal  canal  should  be  emphasized. 
Our  methods  in  this  .direction  may  be  included  under  the  two 
main  heads  of  diet  and  purgation.  The  amount  of  food  detritus 
in  the  alimentary  canal  is  limited  by  the  reduction  of  the  diet 
for  a  variable  length  of  time  before  the  operation.  A  restricted 
diet  for  twenty-four  hours  is  generally  sufficient,  nothing  but 
water  in  small  quantities  being  administered  for  the  last  eight 
or  ten  hours.  As  regards  purgation,  the  method  largely  depends 
upon  the  individual  preference  of  the  operator.  Some  place  their 
confidence  in  broken  doses  of  calomel  followed  by  a  saline,  the 
treatment  being  started  twenty-four  hours  before  the  operation; 
others  depend  upon  a  single  dose  or  repeated  doses  of  a  saline 
alone;  while  yet  others  give  a  single  dose  of  one  ounce  of  castor 
oil  twenty-four  hours  before  the  operation.  But,  whatever  the 
purgative  used,  its  administration  should  sufficiently  precede 
the  hour  of  operation  to  permit  of  thorough  and  repeated  evacua- 
tion of  the  bowels  before  the  patient  is  taken  to  the  operating 
room.  And  it  is  equally  true  that,  whatever  the  form  of  purga- 
tive used,  nearly  all  surgeons  agree  upon  the  use  of  a  final  cleansing 
soapsuds  enema  several  hours  before  the  operation.  The  word 

213 


214  THE  PATIENT 

"  cleansing "  should  here  receive  emphasis.  The  process  is 
more  than  the  simple  administration  of  an  enema.  To  be  cleans- 
ing, the  enema  must  be  repeated  until  a  clear  return  is  obtained, 
and  this  may  require  several  repetitions. 

To  Summarize. — The  patient  is  put  upon  restricted  diet  for 
twenty-four  hours  before  the  proposed  hour  of  operation,  with 
water  only  for  the  last  eight  or  ten  hours.  She  is  given  one  ounce 
of  castor  oil  (or  other  purgative)  at  the  same  time.  Assuming 
the  time  of  the  operation  as  9  A.M.  she  receives  at  6  A.M.  soap- 
suds enema ta  until  a  clear  return. 

The  Reasons. — In  abdominal  operations,  the  degree  of  shock 
to  the  patient  is  increased  or  decreased  proportionately  to  the 
extent  to  which  the  intestines  are  handled  during  the  process 
of  operating.  It  is  perfectly  evident  that  distended  intestines 
are  bound  to  be  more  liable  to  injury  and  manipulation  in  keeping 
from  the  field  of  operation  than  those  which  are  flat  and  empty 
and  easily  pushed  and  kept  to  one  side.  It  is  also  very  evident 
that  a  thoroughly  emptied  intestinal  canal  is  less  likely  to  extrude 
large  quantities  of  infectious  material  into  the  abdominal  cavity, 
if  injured,  than  one  which  is  greatly  distended  with  gas  and  food 
detritus.  Finally,  the  work  of  the  surgeon  is  much  facilitated  by 
the  absence  of  the  coils  of  distended  intestines  constantly  crowd- 
ing the  field  of  operation  and,  consequently,  the  operation  is 
made  shorter  and  the  liability  of  the  patient  to  shock  much 
lessened.  In  addition  to  these  arguments  that  apply  directly 
to  the  time  of  operation,  there  are  those  that  might  be  called 
the  post-operative  considerations;  e.g.,  the  diminished  distention 
and  gas  pains  of  the  patient  after  reacting  from  the  anaesthetic; 
the  lessened  likelihood  of  extreme  nausea  and  vomiting;  and  the 
reduced  danger  of  intestinal  obstruction  from  paralysis  or  me- 
chanical causes. 

B.  Field  of  Operation. — This,  the  second  consideration  in  the 
preparation  of  the  patient,  is  based  upon  the  necessity  for  as 
nearly  perfect  asepsis  as  is  possible,  and  consists  in  two  proced- 
ures,— the  shaving  of  the  field  and  the  sterilization  of  the  field. 
While  the  methods  of  attaining  asepsis  differ  as  widely  as  do 
those  of  purgation  in  the  previous  paragraphs,  we  again  have 
practical  unanimity  upon  the  subject  of  thorough  shaving  the 
day  before  the  operation.  This  is  the  widely  accepted  course, 
although  it  is  true  that  many  of  our  best  surgeons  do  not  require 
the  shaving  until  the  day  of  the  operation.  Where  a  soap  (or 


ROUTINE  NURSING  IN  OPERATIVE  CASES  215 

other)  poultice  is  used  in  the  preparation,  this  early  shaving 
gives  the  poultice  from  twelve  to  eighteen  hours  in  which  to 
accomplish  its  work  before  the  final  preparation.  Where  the 
iodine  preparation  is  used,  it  gives  the  field  of  operation  time  to 
thoroughly  dry  out,  the  presence  of  the  soap  and  water  used  in 
shaving  interfering  with  the  antiseptic  action  of  the  iodine.  The 
process  of  shaving  should  be  a  thorough  one,  care  being  taken, 
however,  to  avoid  the  making  of  any  abrasions  of  the  skin  surface. 
As  a  general  rule,  it  is  better  that  both  abdomen  and  vulva  be 
shaved  for  every  gynaecological  operation,  unless  otherwise 
directed. 

The  next  step  in  the  preparation  of  the  field  of  operation 
consists  in  the  various  steps  that  are  taken  with  the  idea  of 
sterilizing  the  skin.  While  it  is  acknowledged  that  perfect 
sterilization  of  the  skin  is  impossible,  yet  this  desirable  condition 
can  be  nearly  enough  approximated  by  the  methods  in  vogue 
to  render  danger  of  extraneous  infection  practically  nil,  if  the 
technic  of  preparation  is  conscientiously  followed.  The  effort 
has,  naturally,  been  to  find  a  method  of  skin  sterilization  that 
would  combine  simplicity  with  the  aseptic  advantages  of  the 
most  complicated  methods.  The  two  methods  now  most  popu- 
larly accepted  are  the  old  one  where  green  soap  and  water  scrub- 
bing is  followed  by  the  successive  washing  with  alcohol,  ether 
and  a  solution  of  bichloride  of  mercury  in  the  strength  of  1-1000, 
and  the  newer  where  the  field  of  operation  is  simply  painted 
with  the  tincture  of  iodine  (or  a  solution  of  equal  parts  tinc- 
ture of  iodine  and  95  per  cent,  alcohol)  and  permitted  to  dry. 
Either  of  these  methods  gives  the  desired  degree  of  asepsis  and, 
as  a  result,  the  newer  being  the  simpler  is  coming  iuto  widespread 
recognition.  Whichever  method  is  employed,  the  time  of  appli- 
cation is  generally  the  same,  on  the  table,  after  or  during  the 
administration  of  the  anaesthetic. 

II.  ROUTINE  TREATMENT  AFTER  OPERATION 

In  the  average  operative  case,  where  there  is  no  serious  com- 
plication or  sequela  that  may  cause  the  introduction  of  new  ele- 
ments of  care  or  treatment,  the  large  majority  of  surgeons  have 
what  might  be  described  as  an  elastic  routine  treatment.  By 
this  we  mean  that  in  each  operator's  experience  a  certain  method 
of  procedure  has  seemed  to  give  the  best  results  in  the  greatest 
number  of  cases,  so  he  adheres  to  that  routine  where  it  is  not 


216  THE  PATIENT 

contra-indicated  for  one  reason  or  another.  While  it  would,  of 
course,  not  be  feasible  to  enumerate  all  of  the  methods  of  attain- 
ing the  same  end  that  have  grown  up  among  the  various  operators 
of  large  experience,  an  effort  will  be  made  to  draw  what  seems  a 
fair  average  from  the  wealth  of  material;  to  give  a  general  out- 
line of  what  has  proved  acceptable  to  many,  and  to  give  the 
reasons  for  each  step,  so  that  it  may  be  understood  and  the 
reason  for  variation  in  any  particular  technic  appreciated. 

1.  Minor  Steps  for  the  Comfort  of  the  Patient. — The  patient 
who  has  undergone  a  laparotomy  is  brought  back  to  the  ward 
with  an  abdominal  wall  that  has  been  cut,  to  a  greater  or  less 
extent;   that   has   been   pulled  by  retractors   in   the  effort  to 
reveal  the  abdominal  contents;  and  that  has  had  its  contents 
more  or  less  extensively  handled.    Any  one  who  has  endeavored 
to  relieve  a  plain,  old-fashioned  cramp  by  drawing  up  the  knees 
will  see  a  reason  for  putting  a  pillow  under  the  patient's  knees 
as  soon  as  she  shows  signs  of  reacting  from  the  anaesthetic.    The 
great  discomfort  caused  by  the  necessity  of  lying  continuously 
in  the  same  position  is  hard  to  appreciate  by  those  who  have 
not  undergone  the  experience,  but  it  is  sufficiently  great  to  war- 
rant the  frequent  turning  of  the  patient  from  side  to  side  as  she 
complains  of  the  position  she  occupies.     The  feeling  that  a 
patient  must  remain  flat  on  the  back  for  an  indefinite  length  of 
time  has  long  passed  into  the  disuse  that  it  deserved.     These 
two  simple  aids  (the  pillow  under  the  knees  and  the  change  of 
position)  will  add  more  to  the  comfort  of  a  patient  than  all  the 
possible  assurances  of  a  rapid  recovery  or  that  the  pain  will 
soon  wear  off. 

2.  Administration  of  Water. — After  an  anaesthetic  two  points 
arise  in  regard  to  the  administration  of  water.     The  patient  is 
generally  very  thirsty  and,  at  the  same  time,  very  nauseated. 
On  the  treatment  there  is  a  difference  of  opinion.     One  body 
believes  in  the  administration  of  very  small  (teaspoonful)  quan- 
tities of  hot  or  cold  water,  with  the  idea  of  alleviating  the  thirst 
without  increasing  the  nausea.    Others  give  larger  (two  ounces, 
or  more)  quantities,  generally  of  hot  water,  with  the  idea  of 
assuaging  the  thirst,  regardless  of  the  nausea,  believing  that,  if 
the  patient  does  vomit,  this  is  a  very  efficient  way  of  washing  the 
stomach  of  the  ether  that  has  been  swallowed  during  the  admin- 
istration of  the  anaesthetic. 

3.  Nourishment. — The  nausea  following  anaesthesia  does  not 


ROUTINE  NURSING  IN  OPERATIVE  CASES  217 

render  it  advisable  to  administer  any  nourishment  for  several 
hours  after  reaction.  As  soon,  however,  as  the  nausea  permits, 
it  is  desirable  to  start  nourishment  in  such  a  form  as  is  easily 
assimilated  by  the  already  upset  intestinal  tract.  Albumen  water 
is  generally  used  as  a  starter,  being  given  first  in  teaspoonful 
doses,  increased  as  circumstances  permit  until  several  ounces  are 
being  given.  Other  liquids  are  usually  not  administered  until 
the  completion  of  the  first  twenty-four  hours  after  the  operation, 
at  which  time  full  liquid  diet  (without  milk)  is  instituted.  But, 
why  is  milk  omitted?  Owing  to  the  anaesthetic  and  the  manipu- 
lation of  the  intestines  during  the  course  of  operation,  there  is 
a  varying  degree  of  intestinal  paralysis  for  the  first  few  days  after 
an  operation.  This  condition  naturally  favors  the  formation  and 
retention  of  gas.  Intestinal  gas  is  one  of  the  most  prominent 
causes  of  abdominal  pain  following  laparotomy.  With  a  large 
number  of  people,  milk  ingestion  and  gas  formation  are  practically 
synonymous.  It  would  seem  wise,  therefore,  to  leave  the  addition 
of  milk  to  the  dietary  until  after  the  resumption  of  the  bowel 
function, — an  effort  being  made  to  establish  this  at  the  expiration 
of  from  48  to  72  hours  after  the  operation. 

4.  Bladder  Function. — The  question  of  attention  to  and  the 
care  of  the  bladder  function  is  one  that  is  all  too  apt  to  be  slighted, 
when  one  considers  its  importance  and  the  number  of  different 
ways  in  which  its  neglect  may  cause  trouble  and  confusion  to  the 
attendants,  as  well  as  both  these  and  suffering  to  the  patient. 
There  should  be  no  routine  resort  to  the  use  of  the  catheter  in 
after-treatment,  except  in  operation  for  the  correction  of  dis- 
placements of  the  uterus, — and  the  reason  for  the  custom  in  the 
latter  class  of  cases  will  be  given  later.  It  is  well,  however,  to 
emphasize  the  fact  that  the  general  opinion  now  held  is  that  post- 
operative cystitis  more  frequently  follows  overdistention  of  the 
bladder  than  it  does  faulty  technic  in  the  use  of  the  catheter. 
This  means  that  both  surgeon  and  nurse  must  be  constantly  on 
the  alert  for  any  evidences  of  retention  of  urine,  and  that  the 
nurse  should  have  authority  to  catheterize  when  necessary. 

The  ingestion  of  liquids  for  the  last  eight  or  twelve  hours 
before  operation  and  for  several  hours  after  the  return  from  the 
operating  room  is  greatly  diminished.  From  this  cause  and  from 
the  effects  of  the  anaesthetic  upon  the  renal  secretion,  the  output 
of  urine  is  greatly  diminished  during  the  24  hours  immediately 
following  operation.  It  should,  also,  be  noted  that  in  the  ordinary 


218  THE  PATIENT 

routine  preparation  for  laparotomy  the  bladder  is  catheterized 
just  before  operation.  With  the  recent  catheterization  remem- 
bered and  the  reduced  urinary  output  considered,  it  is  evident 
that  there  will  not,  ordinarily,  be  any  call  for  post-operative 
catheterization  until  at  least  12  (and  probably  more)  hours  after 
operation.  And  an  appreciation  of  the  dangers  of  repeated 
catheterization  will  make  every  one  hesitate  before  resorting  to  a 
measure  of  this  sort  unless  there  are  undoubted  indications  for 
its  use.  As  a  rule,  then,  the  catheter  should  not  be  called  into 
use  until  at  least  12  hours  after  an  operation,  and  then  only  in 
the  presence  of  some  definite  indication  and  after  resorting  to 
such  measures  as  we  may  to  encourage  the  patient  to  void.  The 
indications  for  the  use  of  the  catheter  are,  of  course,  a  distended 
bladder  which  must  be  relieved  or  as  a  diagnostic  aid  in  suspected 
suppression  of  urine.  The  aids  to  inducing  spontaneous  evac- 
uation of  the  bladder  are :  (a)  the  sound  of  running  water,  which 
is  not  infrequently  efficacious;  (6)  the  pouring  of  warm  water 
over  the  vulva,  which  will  sometimes  succeed  when  the  preceding 
measure  fails;  (c)  lastly,  the  administration  of  an  enema,  with 
the  return  of  which  the  bladder  is  frequently  evacuated.  If 
these  measures  fail,  it  is  then  time  to  resort  to  the  use  of  the 
catheter.  Naturally,  there  are  times  when  it  is  not  desirable  to 
use  enemata  so  early  after  operation,  and  in  such  cases  it  is 
sometimes  necessary  to  use  the  catheter  earlier. 

In  operations  upon  the  round  ligaments  for  retrodisplacement 
of  the  uterus,  the  weight  of  the  distended  bladder  upon  the  uterus 
is  to  be  avoided  during  the  first  24  hours  after  operation,  lest 
the  success  of  the  operation  be  endangered  through  the  strain 
placed  upon  the  transplanted  ligaments.  In  such  cases,  there 
is  no  way  of  avoiding  use  of  the  catheter  and  it  is  customary, 
in  some  hospitals,  to  have  the  patient  catheterized  every  eight 
hours  after  the  catheterization  on  the  table  for  the  first  24  hours  or 
more.  But  it  must  be  borne  in  mind  that  the  catheter  demands 
all  of  the  precautions  used  for  any  aseptic  proceeding  that 
involves  the  entrance  into  any  of  the  clean  cavities  of  the  body. 
An  infection  of  the  bladder  is  a  serious  matter  for  both  the  surgeon 
and  patient,  and  the  accompanying  danger  of  an  ascending 
infection  to  the  kidneys  must  be  an  ever-present  bugbear  of 
warning  to  the  person  bearing  the  responsibility  of  the  catheteri- 
zation. It  is  a  point  upon  which  there  is  no  possibility  of  over- 
emphasis and  upon  which  reiteration  is  perfectly  excusable.  A 


ROUTINE  NURSING  IN  OPERATIVE  CASES  219 

bladder  infection,  while  possibly  not  the  most  unusual  accident 
of  surgical  technic  and  possibly,  also,  not  the  most  inexcusable, 
is  in  all  probability  the  most  unexcused,  with  the  possible  excep- 
tion of  an  abscess  following  hypodermic  medication. 

5.  Bowel  Function. — For  somewhat  the  same  reasons  that 
apply  to  the  bladder  function,  the  bowel  function  is  partially 
inhibited  during  the  first  few  days  following  an  operation  that 
involves  manipulation  of  the  abdominal  contents.    The  action  of 
the  anaesthetic,  combined  with  the  handling  of  the  intestines  and 
the  absence  of  foodstuffs  that  have  a  marked  residue,  gives  the 
double  effect  of  partial  paralysis  of  the  intestinal  walls  and  the 
absence  of  the  normal  bowel  stimuli.     There  is,  therefore,  no 
object  in  the  early  administration  of  enemata  and  cathartics, 
save  the  possible  presence  of  large  quantities  of  gas.    The  custom 
has  therefore  gained  common  use  of  refraining  from  the  use  of 
any  intestinal  stimulant  during  the  first  two  or  three  days  after 
laparotomy,  at  which  time  the  resumption  of  the  bowel  function 
is  encouraged  by  the  administration  of  a  simple  enema.     From 
this  time  on,  if  simple  enemata  are  successful,  the  bowels  are 
moved  once  daily  by  this  measure  until  the  seventh  day.    Should, 
however,  the  simple  enema  prove  insufficient  to  attain  the  desired 
end,  a  hypodermic  injection  of  physoetigmine  salicylate  gr.  Xoand 
strychnine  sulphate  gr.  Ka  may  be  given  and  followed  in  half  an 
hour  by  a  purgative  enema.     The  intra-muscular  injection  of 
1  c.c.  of  pituitrin  may  prove  even  more  efficacious  than  physostig- 
mine.    After  the  seventh  day,  should  the  bowels  still  prove  recal- 
citrant, the  enemata  should  be  discontinued  and  some  medica- 
ment that  has  a  stimulating  effect  upon  the  intestinal  muscula- 
ture substituted, — such  preparations  as  the  pill  of  aloin,  strychnine 
and  belladonna,  cascara,  or  something  similar  generally  proving 
satisfactory. 

6.  Opiates. — Only  passing  mention  will  be  made  of  this  rather 
important  problem  in  operative  after-treatment,  as  the  subject 
is  one  that  rests  solely  in  the  hands  of  the  attending  surgeon  and 
can  be  decided  by  him  only.    Opiates  are,  as  would  be  naturally 
supposed,  indicated  where  the  pain  is  sufficiently  severe  to  re- 
quire attention  and  the  simpler  methods  prove  inadequate.    The 
preparations  most  frequently  used  are  the  sulphate  of  morphine, 
the  sulphate  or  phosphate  of  codeine  and  the  hydrochloride  of 
heroin.      These    medicaments    are   generally   administered   by 
hypodermic  injection  and  in  doses  up  to  gr.  %  gr.  Kand  gr.  %, 


220  THE  PATIENT 

respectively.  Owing  to  their  increased  effect  upon  the  intestinal 
paralysis  already  existing,  it  is  generally  accepted  that  no  more 
should  be  given  than  is  absolutely  necessary  for  the  comfort  of 
the  patient  and  then  discontinued  at  the  earliest  possible  moment. 
In  the  limited  use  occasioned  after  operation,  the  question  of 
habit  formation  does  not  usually  come  up  for  consideration. 

7.  Dressings. — The  question  of  dressing  is  one  that  depends 
upon  the  suture  material  used  and  the  condition  of  the  wound. 
Where  the  wound  is  clean  and  absorbable  suture  material  is  used, 
there  is  generally  no  necessity  for  dressing  the  operative  wound 
until  the  fourteenth  day.    Where  non-absorbable  suture  material 
is  used  and  must  be  removed,  the  time  for  dressing  depends  upon 
the  nature  of  the  material  and  the  method  of  its  use.    If  the  non- 
absorbable  suture  material  is  fine  silk  used  as  a  running  skin 
suture,  it  may  be  removed  from  the  fifth  day  on,  dependent  upon 
the  method  of  closure  employed  for  the  rest  of  the  abdominal 
wall.    If  silkworm-gut  through-and-through  sutures  are  used  for 
support  they  should  be  removed  about  the  tenth  day,  as  they 
have  a  tendency  to  cut  out  and  cause  considerable  irritation  and 
discomfort.    If  a  subcuticular  silver  wire  suture  is  used  for  skin 
approximation,  it  should  be  removed  about  the  fourteenth  day. 

8.  Sitting  Up. — After  the  average  gynaecological  laparotomy, 
the  patient  may  be  permitted  to  sit  up  out  of  bed  for  a  few  minutes 
on  from  the  tenth  to  the  fourteenth  day.     The  custom  varies 
considerably  with  different  surgeons,  but  the  above  limits  may 
be  accepted  as  the  early  and  late  limits  of  the  conservative  ele- 
ment.   In  minor  cases,  such  as  curettage,  trachelorrhaphy,  and 
perineorrhaphy,  the  patient  may  be  permitted  to  get  up  anywhere 
from  the  seventh  to  the  tenth  day.    It  should,  however,  be  under- 
stood that  permission  to  get  up  out  of  bed  after  a  laparotomy 
does  not  convey  the  idea  of  a  whole  day  (nor  even  a  half  day) 
sitting  in  a  chair.    The  first  venture  should  not  be  for  more  than 
a  few  minutes, — half  an  hour  at  the  outside.    The  next  day,  the 
length  of  time  may  be  somewhat  increased  and  repeated  in  the 
afternoon.    By  this  gradual  method,  the  strength  of  the  patient 
is  increased  by  degrees  corresponding  to  her  endurance.    If  she 
does- not  feel  any  fatigue  after  the  first  day,  the  natural  inference 
is  that  she  will  bear  a  longer  siege  on  the  second  day  than  will 
the  patient  who  is  exhausted  by  a  fifteen  minutes'  seance  on  the 
first  attempt. 

9.  Going  Home. — If  all  has  gone  well  from  the  time  of  the 


ROUTINE  NURSING  IN  OPERATIVE  CASES  221 

operation  and  there  has  been  no  seriously  run-down  condition 
already  existing  to  make  the  convalescence  protracted,  the  patient 
may  ordinarily  be  permitted  to  return  to  her  home  at  the  expira- 
tion of  three  weeks  after  the  operation.  Of  course,  this  period 
is  not  a  definite  nor  an  invariable  one.  The  condition  and 
home  circumstances  of  one  patient  may  be  such  as  to  make  an 
early  return  desirable,  and,  in  another,  quite  the  contrary  may 
be  the  case. 

10.  Belts,  Binders  and  Supports. — The  question  that  is  fre- 
quently asked  by  a  patient,  following  an  abdominal  operation 
and  preceding  her  return  to  her  home,  concerns  the  advisability 
or  necessity  of  wearing  some  form  of  abdominal  supporter.  In  a 
well-nurtured  woman,  with  muscular,  firm  abdominal  walls,  the 
use  of  a  support  is  to  be  discouraged.  If  the  abdominal  walls 
are  greatly  relaxed  and  weakened  from  the  extended  presence 
of  a  large  tumor  or,  if  there  has  been  infection  present  that  neces- 
sitated the  use  of  prolonged  drainage,  it  may  be  well  to  use  some 
form  of  corset  or  binder  that  will  give  the  necessary  support 
until  the  walls  have  regained  their  natural  strength  and  tone. 


CHAPTER  XVII 
POST-OPERATIVE  COMPLICATIONS 

No  effort  will  be  made  to  consider  this  rather  extensive  subject 
from  the  view-point  of  the  surgeon,  as  the  diagnosis  and  treat- 
ment of  the  different  conditions  should  not  devolve  upon  the 
nurse.  An  effort  will,  however,  be  made  to  so  present  the  more 
common  of  these  complications  that  the  nurse  will  get  a  fair 
picture  of  the  cardinal  signs  and  symptoms  in  each  case,  with  the 
idea  of  showing  the  great  importance  of  accurate  charting  of 
even  the  most  routine  and,  apparently,  unimportant  events. 
The  causes,  so  far  as  known,  will  be  included  in  the  description, 
in  order  to  promote  the  intelligent  cooperation  between  physician 
and  nurse  that  is  so  important  for  the  best  interests  of  the  patient. 

I.  SHOCK 

The  cause  of  operative  (or  post-operative)  shock  is  not 
thoroughly  understood.  The  predisposing  causes  are,  however, 
fairly  well  recognized  and  accepted.  Among  the  more  important 
of  these  are  prolonged  anaesthesia ;  undue  exposure  of  the  patient 
before,  during  or  immediately  after  operation;  excessive  handling 
of  the  viscera;  loss  of  blood;  extensive  trauma;  and  severe  tox- 
semia.  The  occurrence  of  shock,  as  might  be  expected,  is  also 
influenced  by  the  character  and  extent  of  the  operative  procedure. 

The  occurrence  may  be  at  any  time  from  during  the  operation 
to  a  few  hours  after  the  return  of  the  patient  to  her  bed. 

The  signs  and  symptoms  are  pallor;  coolness  of  the  skin  sur- 
face, frequently  accompanied  by  cold  sweat;  fall  of  the  tempera- 
ture, possibly  to  subnormal;  rapid,  irregular  and  weak  pulse; 
increased  and  irregular  respirations;  more  or  less  mental  dulness; 
and  a  general  appearance  of  some  severe  crisis. 

II.  HEMORRHAGE 

Post-operative  hemorrhage  (disregarding  the  classes  into 
which  it  has  been  divided)  is  one  of  the  most  serious  and,  fortu- 
nately, most  rare  of  the  complications  or  sequelae  with  which  we 
have  to  deal.  The  causes  are  generally  one  of  three :  the  failure 
to  ligate  a  severed  vessel  at  the  time  of  operation;  the  slipping 
222 


POST-OPERATIVE  COMPLICATIONS  223 

of  a  ligature  on  a  tied  vessel;  or,  in  the  later  cases,  opening  of  a 
vessel  due  to  the  separation  of  a  slough.  The  occurrence  may 
be  at  any  time  during  the  first  week. 

The  symptoms  may  come  on  suddenly  or  gradually,  dependent 
upon  the  size  of  the  vessel  involved  and  the  lack  of  interference 
with  the  flow  by  surrounding  tissues.  In  the  more  gradual  form 
of  hemorrhage,  there  is  a  steady  increase  in  the  pulse  rate  with 
a  corresponding  decrease  in  volume;  the  respirations  become  more 
rapid  and  shallow;  the  temperature  falls,  frequently  to  subnormal; 
there  are  pallor,  restlessness,  precordial  distress,  dizziness,  pain 
at  site  of  hemorrhage  and,  frequently,  fear  of  approaching  death. 

Where  the  vessel  is  a  large  one  and  there  is  no  interference 
with  the  flow,  the  change  is  sudden  and  marked.  The  sharp  pain 
(particularly  if  the  hemorrhage  is  intraperitoneal)  is  quickly  fol- 
lowed by  the  restlessness,  pallor,  air-hunger,  rapid  fluttering 
pulse,  precordial  distress,  fear  of  impending  dissolution  and,  in 
the  end,  death.  In  the  latter  cases,  the  patient  may  have  passed 
through  the  succeeding  stages  so  quickly  that  death  will  have 
supervened  before  the  house  physician  can  be  summoned. 

III.  ACUTE  DILATATION  OF  THE  STOMACH 

The  onset  of  this  condition  is  apt  to  be  sudden  and  alarming. 
Large  quantities  of  fluid,  out  of  all  proportion  to  the  amount 
ingested,  are  vomited.  There  are  frequent  eructations  of  gas. 
And  collapse  is  an  early  symptom.  The  temperature  is  either 
not  elevated,  or  only  slightly  so.  The  pulse  is  rapid  and  weak. 
The  respirations  are  increased  in  frequency  and  often  show 
marked  dyspnoea.  There  is  distention  in  the  region  of  the 
stomach,  without  any  visible  peristalsis. 

IV.  INTESTINAL  OBSTRUCTION 

The  most  common  cause  of  post-operative  intestinal  obstruc- 
tion is  the  formation  of  intestinal  adhesions.  These  may  act 
by  causing  kinking  of  the  intestines  or  by  the  formation  of  bands. 
Other  less  common  post-operative  causes  are  volvulus,  hernia  and 
intussusception. 

Obstruction  of  the  bowels  may  occur  at  any  time,  from  days 
to  months  after  the  operation.  The  symptoms,  in  the  more  acute 
forms,  are  distention;  pain;  anorexia;  nausea;  vomiting,  the  latter 
becoming  progressively  worse  and  finally  in  many  cases  contain- 
ing fecal  matter;  increase  in  rapidity  of  pulse  and  respiration, 


224  THE  PATIENT 

accompanied  by  a  low  and  frequently  subnormal  temperature; 
and  inability  to  move  the  bowels  by  enemata.  In  such  cases, 
there  is  generally  early  collapse  unless  the  condition  is  promptly 
relieved  by  operative  measures. 

V.  INFECTIONS 

The  infections  (as  the  name  would  indicate)  are  the  result 
of  the  presence  or  introduction  of  pathogenic  bacteria.  They 
may  be  either  local  or  general. 

1.  The  simplest  of  the  local  infections  is  the  stitch  abscess 
and,  after  that,  the  mild  wound  infection.  Of  course,  the  latter 
may  vary  in  degree  from  a  very  simple  matter  to?a  fairly  serious 
one,  but,  in  the  general  run  of  cases,  it  is  one  of  the  simplest  of 
the  post-operative  complications.  The  cause  of  such  infections 
is,  necessarily,  the  introduction  of  some  pathogenic  microorgan- 
ism either  from  within  or  from  without.  The  staphylococcus 
is  the  most  common  organism  found  in  these  cases,  although 
B.  coli  communis,  B.  pyocyaneus  and  others  are  found  not 
infrequently. 

The  occurrence  is  generally  from  the  third  to  the  eighth  day 
and  is  accompanied  by  an  elevation  of  temperature  (102°  to 
103°  F.),  local  pain  and  tenderness,  headache,  loss  of  appetite 
and  general  discomfort.  The  symptoms  are,  in  other  words, 
those  that  would  be  expected  to  accompany  a  mild  infection. 

2.  Sapraemia. — This   condition  is  due  to  the  absorption  of 
the  products  of  decomposing  tissue  which  is  acted  upon  by  the 
bacteria  of  putrefaction.    The  onset  is  sudden,  generally  within 
a  few  hours  of  the  exposure  of  raw  surfaces  to  absorption  from 
decomposing  tissues.     The  symptoms  (which  may  arise  from  a 
few  hours  to  several  days  after  operative  or  obstetric  procedure) 
are  a  sudden  rise  of  temperature  to  from  102°  to  104°  F.,  fre- 
quently accompanied  by  a  chill;  a  rapid  and  full  pulse;  increased 
respirations;  anorexia;  headache;  thirst;  and,  sometimes,  nausea. 
The  face  is  flushed;  the  tongue  coated;  and  the  urine  is  scanty 
and  highly  colored. 

3.  Peritonitis. — Peritonitis  may  be  either  local  or  diffuse.    The 
local  form  may  be  caused  by  mechanical,  chemical  or  bacterial 
agents.     The  symptoms  are  the  same  as  would  be  expected  in  a 
localized  inflammation  in  any  other  region,  with  the  symptoms 
peculiar  to  intra-abdominal  affection  superimposed.    We,  there- 
fore, have  pain,  tenderness,  elevation  of  temperature,  increase 


POST-OPERATIVE  COMPLICATIONS  225 

of  pulse  and  respiration,  anorexia  and  possibly  nausea  and 
vomiting.  In  addition  to  those,  we  have  abdominal  distention, 
general  or  localized  rigidity  of  the  abdominal  muscles,  sometimes 
a  palpable  tumor  and,  probably,  either  diarrhoea  or  constipation, 
the  latter  being  more  common. 

Diffuse  peritonitis  is  due  to  the  presence  of  pathogenic  micro- 
organisms in  the  abdominal  cavity  under  conditions  that  favor 
the  extensive  spreading  of  the  inflammatory  process.  These 
conditions  may  be  dependent  upon  the  method  of  introduction, 
quantity  of  infectious  material,  character  of  the  organism  or 
reduced  resistance  of  the  patient.  The  onset  is  gradual,  the 
symptoms  usually  making  their  appearance  from  twenty-four  to 
forty-eight  hours  after  operation.  At  first,  there  is  localized  pain, 
which  afterwards  is  general  throughout  the  abdomen.  This  is 
intense  in  character,  accounting  for  the  position  generally  as- 
sumed by  these  patients — with  the  thighs  flexed  on  the  body  and 
the  shoulders  elevated  in  the  effort  to  relieve  the  tension  of  the 
abdominal  muscles.  During  the  earlier  stages,  the  abdominal 
muscles  are  contracted — the  walls  being  at  times  retracted  as  a 
result.  Later  there  is  extreme  distention.  The  respiration  is  of 
the  thoracic  type — also  as  a  result  of  the  abdominal  tenderness 
and  distention — and  the  tympany  marked.  A  very  rapid  pulse 
is  generally  an  early  symptom,  being  accompanied  by  a  rise  of 
temperature  to  from  101°  to  104°  F.,  which  may  reach  as  high 
as  110°  shortly  before  death.  The  elevation  of  temperature 
is,  however,  not  constant,  as,  in  rapidly  fatal  cases,  it  some- 
times remains  practically  normal  throughout  the  course  of  the 
disease.  There  is  early  and  persistent  vomiting,  which  may, 
during  the  later  stages,  become  fecal  in  character.  The  action 
of  the  bowels  is  not  constant,  either  diarrhoea  or  constipation 
occurring;  the  latter,  however,  being  the  more  persistent  and 
common  symptom.  Hiccough  is  also  a  very  common  symptom, 
appearing  early  in  the  course  of  the  disease  and  being  persistent 
in  character. 

4.  Septicaemia. — Septicaemia  is  a  result  of  the  presence  of 
bacteria  and  their  products  in  the  blood  stream.  The  most 
common  of  the  organisms  found  in  this  condition  are  the  Strepto- 
coccus pyogenes  and  the  Staphylococcus  pyogenes  aureus  and 
albus.  The  symptoms  arise  in  anywhere  from  a  few  hours  to 
several  days,  being  usually  ushered  in  by  an  initial  chill.  There 
is  an  elevation  of  temperature  to  from  103°  to  105°  F.,  usually 
15 


226  THE  PATIENT 

with  a  slight  daily  remission.  The  pulse  is  small  and  rapid  and 
the  respirations  are  usually  increased  in  number  in  proportion 
to  the  pulse.  The  other  symptoms  are  those  common  to 
all  infections:  anorexia,  nausea,  vomiting,  scanty  and  highly- 
colored  urine,  and,  sometimes,  diarrhoaa. 

5.  Septico=Pysemia. — This  condition,  which  is  now  rarely 
met  with  as  a  sequela  of  operative  procedure,  may  be  described 
as  septicaemia  complicated  by  the  formation  of  multiple  ab- 
scesses. We  have,  therefore,  the  presence  of  bacteria  and  their 
products  in  the  blood  stream  as  is  the  case  in  septicaemia  and, 
further,  we  have  the  formation  from  time  to  time  during  the 
progress  of  the  disease  of  abscesses.  These  abscesses  may  be 
superficial  (in  which  case  the  condition  is  apt  to  be  more  favor- 
able) or  they  may  be  located  in  the  most  inaccessible  regions,  as 
the  lungs.  The  condition  is  usually  fatal,  except  in  its  mildest 
forms.  The  symptoms  are  those  of  septicaemia,  at  the  beginning, 
but,  as  the  disease  progresses,  the  initial  chill  is  repeated  at 
irregular  intervals,  probably  with  the  formation  of  new  abscesses. 
With  each  chill  there  is  a  following  more  pronounced  rise  of 
temperature.  With  the  evacuation  of  the  abscess  contents 
(either  by  incision  or  spontaneous  rupture),  there  is  temporary 
improvement  in  the  condition  of  the  patient,  to  be  followed  by 
another  chill,  another  rise  of  temperature  and  gradually  dimin- 
ishing strength  as  the  disease  progresses.  The  duration  of  the 
condition  may  be  abbreviated  where  the  infection  is  particularly 
virulent  or  where  the  resistance  of  the  patient  is  already  greatly 
lessened  by  preexisting  disease.  Usually,  however,  the  course 
is  prolonged  (sometimes  for  weeks),  the  patient  steadily  losing 
ground,  but  having  short  periods  of  temporary  improvement. 

VI.  PULMONARY 

The  most  common  of  the  pulmonary  complications  of  con- 
valescents from  operative  measures  are  lobar  and  broncho- 
pneumonia.  The  predisposing  causes  are  a  lowered  resistance 
from  any  cause,  and  undue  exposure  of  the  patient  before,  during 
or  after  the  operation.  The  exciting  causes  are  bacteria  and, 
more  rarely,  the  inspiration  of  foreign  materials. 

The  onset  and  course  of  the  lobar  form  do  not  materially 
differ  from  the  pure  form  of  the  disease,  except  as  the  diagnosis 
may  be  clouded  by  the  other  conditions  following  operation.  The 
early  pain  in  the  chest,  the  chill  and  initial  rise  of  temperature, 


POST-OPERATIVE  COMPLICATIONS  227 

the  increase  of  pulse  rate  with  disproportionate  increase  of 
respiratory  rate,  the  cough  and  characteristic  sputum,  and  the 
recovery  by  crisis  are  all  similar,  although  the  onset  may  be 
missed  or  confused  with  other  possible  sequelae  or  complications. 
In  bronchopneumonia,  the  onset  and  course  of  the  disease 
are  very  much  less  characteristic  and  the  diagnosis  must  rest 
upon  a  careful  study  of  symptoms,  the  exclusion  of  other  trouble 
and,  finally,  the  findings  on  physical  examination,  which,  too 
often,  are  very  indefinite. 

VII.  URINARY  SYSTEM 

There  are  four  conditions  of  the  urinary  system  that,  while 
not  confined  in  their  appearance  to  following  operations,  do, 
with  varying  degree  of  frequency,  complicate  convalescence. 
These  are,  in  the  reverse  order  of  their  possible  serious  import, 
retention  of  urine;  retention  with  overflow  (sometimes  called 
"  paradoxical  incontinence"))  incontinence  of  urine;  and  sup- 
pression of  urine. 

1.  Retention  of  Urine. — Simple  retention  of  urine  is  a  very 
frequent  and,  usually,  a  very  slight  sequela  of  operations  under 
general  anaesthesia.    The  tentative  diagnosis  is  usually  made  by 
either  the  nurse  or  the  patient.    If  the  introduction  of  a  catheter 
is  rewarded  by  a  free  return  flow  of  urine,  the  diagnosis  is,  natu- 
rally,  confirmed.  There  are,   however,   two  very  real   dangers 
associated  with  this  very  simple  condition,  one  very  remote  and 
the  other  imminent.     There  is  always  the  possibility,  however 
remote,  of  the  overdistended  bladder  rupturing,  with  the  occur- 
rence of  a  diffuse  peritonitis  an  almost  certain  accompaniment. 
There  is,  besides,  the  not  infrequent  occurrence  of  cystitis  (from 
incorrect  technic)  to  be  considered  and  guarded  against. 

2.  Retention  with  Overflow. — The  dangers  of  this  condition 
are  identical  with  those  of  the  preceding,  somewhat  increased 
by  the  possibility  of  a  delayed  or  mistaken  diagnosis  of  the  true 
condition.     Here,  while  in  truth  an  almost  complete  retention 
is  present,  there  is  often  sufficient  dribbling  of  urine  to  give  the 
false  impression  of  incontinence.     Where  the  suprapubic  area  is 
covered  by  dressings  after  an  abdominal  operation,  it  is  some- 
times difficult  to  determine  by  examination  the  presence  of  an 
overdistended  bladder.     Where,  however,  there  is  the  possibility 
of  such  a  condition  existing,  all  doubt  may  be  easily  removed  by 
the  passage  of  a  catheter. 


228  THE  PATIENT 

3.  Incontinence  of  Urine  (Enuresis). — This  condition  is  not 
a  very  common  one  as  a  sequela  of  surgical  procedure,  most  fre- 
quently occurring  as  a  result  of  temporary  paralysis  of  the  bladder 
sphincter  or  actual  injury  thereto  in  the  course  of  the  operative 
procedure.     The  constant  dribbling  of  urine  or  the  occasional 
gush  as  the  bladder  becomes  distended  is  of  itself  very  distressing 
to  the  patient,  although  (if  of  the  simple  form)  it  generally  is  of 
very  short  duration.    Where  the  amount  of  urine  discharged  in 
the  course  of  several  hours  is  such  as  to  indicate  a  normal  secre- 
tion for  that  length  of  time,  there  is  very  little  room  for  confusing 
this  condition  with  any  other, — retention  with  overflow  being  the 
one  most  nearly  resembling  it  and  eliminated  by  the  amount  of 
urine  discharged. 

4.  Suppression  of  Urine. — This  condition  (fortunately  not  a 
very  frequent  complication  of  operations)  is  necessarily  serious. 
The  failure  of  a  patient  to  void  urine  within  twelve  hours  after 
operation  should  be  followed  by  catheterization  for  the  purpose 
of  deciding  between  the  two  possibilities  of  retention  or  suppres- 
sion of  urine.     The  early  diagnosis  and  prompt  institution  of 
treatment  are  essential  for  the  welfare  of  the  patient. 

In  summary  of  the  various  features  that  may  characterize 
these  more  common  sequelae  of  operations  (more  particularly 
abdominal  operations),  it  is  evident  that  a  careful  charting  of 
the  subjective  symptoms  of  the  patient — the  temperature,  pulse 
and  respiration — so  that  any  marked  deviation  from  their  nor- 
mal ratio  may  be  noted;  of  the  absence  or  presence  of  nausea, 
vomiting  or  hiccough;  the  absence  or  presence  of  bowel  move- 
ments, with  the  character  of  the  movement  and  the  fact  that  gas 
is  or  is  not  passed;  the  voiding  or  retention  of  urine,  whether  the 
former  is  voluntary  or  involuntary,  profuse  or  scant  and  dribbling; 
the  presence  of  cough;  and  the  presence,  location  and  character 
of  pain,  is  a  matter  of  the  utmost  importance,  particularly  in 
those  conditions  where  an  early  diagnosis  is  practically  imperative 
for  the  welfare  of  the  pa,tient. 


CHAPTER  XVIII 

ANOCI-ASSOCIATION 
I.  SHOCK  AND  FEAR 

No  one  will  be  inclined  to  question  that  great  anxiety  and 
fear,  together  with  the  emotional  strain  incident  to  physical 
pain,  may  have  a  decided  influence  upon  a  patient's  fitness  to 
meet  the  ordeal  of  an  operation,  and  hence  become  a  factor  in 
the  operative  risk,  but  it  is  only  in  very  recent  years  that  any 
systematic  study  has  been  directed  to  this  subject.  That  both 
strong  emotion  and  physical  injury  play  an  important  part  in 
causing  the  condition  we  know  as  shock  has,  of  course,  always 
been  recognized,  but  our  knowledge  of  the  true  nature  of  this 
causal  relation  was  of  too  vague  a  character  to  be  of  any  practical 
use  to  us  in  suggesting  ways  of  preventing  and  treating  the  condi- 
tion of  shock.  We  have  had,  in  consequence,  almost  nothing  in 
the  way  of  a  standardized  technic  for  the  management  of  patients 
with  reference  to  this  aspect  of  our  problem. 

We  owe  to  Dr.  George  Crile  a  series  of  experimental  and 
clinical  researches  which  throw  a  wholly  new  light  upon  this 
subject.  The  practical  result  of  these  studies  has  been  the  devel- 
opment of  a  new  technic  in  the  management  of  patients  who  are 
to  be  operated  upon.  These  new  methods  have  now  been  in 
actual  use  in  the  Lakeside  Hospital  in  Cleveland,  Ohio,  where 
Dr.  Crile  is  the  visiting  surgeon,  and  in  a  few  others  for  several 
years,  and  have  resulted  in  a  most  striking  reduction  in  operative 
mortality  and  in  post-operative  morbidity.  That  part  of  the 
new  method  which  consists  of  manipulative  measures  is  quite 
simple  and  can  be  easily  described.  Another  and  very  important 
part,  however,  which  relates  to  the  control  of  the  patient's  con- 
tact, mentally,  with  the  conditions  which  surround  him  from  the 
time  an  operation  is  first  proposed  until  it  is  over  and  he  is  re- 
stored to  health,  cannot  be  so  easily  presented  in  the  form  of 
exact  directions.  Here  much  will  depend  upon  the  personality  of 
the  surgeon  and  also  of  the  nurse  who  is  in  immediate  charge  of 
the  case.  The  part  of  the  nurse  will  be  of  great  importance,  and 

229 


230  THE  PATIENT 

in  order  that  she  may  enact  it  well  it  is  necessary  for  her  to  under- 
stand as  clearly  as  possible  the  nature  of  the  problem. 

Let  us  ask  at  the  outset  the  question,  What  are  the  principal 
physical  phenomena  attendant  upon  extreme  fright,  i.e.,  the 
symptoms  of  fear?  They  are  rapid  action  of  the  heart,  increased 
rate  of  respiration,  pallor  of  the  skin,  sweating,  dilatation  of  the 
pupils  of  the  eyes,  muscular  relaxation,  organic  sensations  of 
weakness  described  in  common  language  as  a  "  sinking  "  feeling, 
and  disturbance  of  the  digestive  functions.  Now  let  us  ask  a 
second  question  of  the  same  kind.  What  are  the  symptoms 
caused  by  severe  and  prolonged  muscular  exertion?  The  answer 
is  exactly  the  same:  muscular  exertion  carried  to  the  point  of 
extreme  exhaustion  gives  rise  to  the  same  condition  in  the  body 
as  does  the  emotion  of  fear  at  its  highest  intensity.  We  may  now 
ask  a  third  question :  What  are  the  symptoms  of  shock  resulting 
from  severe  physical  injury?  Again  the  answer  is  the  same;  word 
for  word,  the  answer  to  the  first  question  will  stand  for  an  answer 
to  the  second  or  the  third.  We  can,  of  course,  point  out  minor 
differences,  but  in  all  essentials  the  effects  of  fear,  of  exhaustion 
from  severe  exertion,  and  of  shock  from  severe  injury  are  identical 
and  as  a  matter  of  fact  one  cannot  always  tell  at  the  first  glance 
whether  a  man  is  badly  scared,  or  badly  hurt,  or  exhausted  from 
overexertion. 

Wherever  we  find  effects  so  closely  corresponding  as  in  these 
cases  it  is  natural  and  reasonable  to  assume  that  the  causes 
which  produce  these  effects  are  also  identical.  Let  us  see,  there- 
fore, if  we  can  find  any  common  cause  at  work  in  each  of  these 
three  widely  different  conditions.  In  what  exact  way  does  fear 
cause  these  phenomena;  in  what  way  does  muscular  exertion 
cause  them;  how  does  physical  injury  cause  them?  Now  in  the 
second  case,  that  of  severe  muscular  exertion,  the  answer  seems 
obvious  enough.  It  is  a  case  of  exhaustion;  the  muscles  have 
done  a  tremendous  amount  of  work  and  are,  as  we  say,  tired  out. 
If  we  put  it  in  mechanical  terms  we  may  say  that  the  muscles 
have  used  up  all  the  energy-giving  substances  from  which  their 
power  is  derived,  and  they  lose  power  just  as  a  steam  engine  does 
when  all  the  coal  in  its  furnaces  is  burned  out,  and  all  the  water 
in  its  boiler  is  turned  into  steam.  There  has  been  in  this  case  an 
immense  draft  upon  the  reserve  energy  of  the  body,  and,  because 
we  are  familiar  with  the  idea,  it  seems  natural  to  us  that  the 
whole  body  should  share  in  the  exhaustion  which  follows,  and 


ANOCI-ASSOCIATION  231 

it  is  easy  to  understand  that  the  nerve-cells  of  the  brain,  which 
control  and  direct  the  movements  of  the  muscles,  should  espe- 
cially partake  of  the  effects  of  muscular  exhaustion. 

Now  fear  and  injury  both,  under  natural  conditions,  produce 
intense  muscular  effort.  For  both  arouse  the  instinct  of  self- 
preservation,  which  expresses  itself  in  two  forms,  the  impulse  to 
fight  and  the  impulse  to  run  away.  Perhaps  a  third  form  may 
be  distinguished  in  the  instinct  to  struggle  when  in  the  actual 
grip  of  something  that  hurts.  Whichever  form  the  instinct  takes, 
great  expenditure  of  muscular  energy  is  called  for,  with  an  equal 
expenditure,  though  one  that  is  silent  and  invisible,  in  the  cells 
of  the  brain  whose  activity  drives  the  motor  mechanism.  When 
the  impulse  of  flight  predominates  emotion  takes  the  form  of  fear. 
With  the  fighting  impulse  another  emotion  appears,  that  of 
anger,  which,  when  in  high  intensity,  also  leads  to  rapid  exhaus- 
tion. In  the  case  of  the  struggle  against  anything  that  hurts,  the 
emotion  aroused  seems  to  be  a  blending  of  the  other  two. 

Even  when  the  grosser  physical  manifestations  of  these  emo- 
tions, such  as  actual  flight  or  struggle,  are  suppressed,  there  are 
inner  physical  effects  connected  with  them,  beyond  the  reach 
of  the  will,  that  apparently  produce  the  same  exhausting  effects. 
Probably,  also,  the  very  effort  to  suppress  the  more  visible 
muscular  exertions  is  itself  highly  exhausting.  In  Dr.  Crile's 
researches,  actual  microscopical  study  in  the  laboratory  of  hun- 
dreds of  animal  and  human  brains  and  of  thousands  of  nerve-cells 
has  shown  changes  characteristic  of  cell  exhaustion,  resulting 
from  each  of  the  three  causes,  physical  exertion,  physical  injury 
and  fear. 

Dr.  Crile  has  also  shown  that  even  in  an  animal  anaesthetized 
by  ether  the  impulses  received  by  the  brain  along  the  nerves 
leading  from  the  part  of  the  body  that  is  injured  bring  about 
changes  that  produce  exhaustion  in  the  brain-cells  almost  as 
severe  as  if  no  anaesthetic  had  been  used.  When  nitrous  oxide 
and  oxygen  was  the  anaesthetic  used,  the  evidence  of  exhaustion 
in  brain-cells  was  much  less.  When  a  part  of  the  body  was  com- 
pletely cut  off  from  connection  with  the  brain,  as  by  division  of  the 
spinal  cord,  then  no  amount  of  injury  of  this  disconnected  part 
would  cause  any  appearance  of  exhaustion  in  brain-cells  or  any 
symptoms  of  shock.  We  have  here  then  two  new  facts  which 
can  be  practically  applied  in  the  prevention  of  shock.  First,  we 
have  learned  that  ether,  while  it  obliterates  consciousness,  does 


232  THE  PATIENT 

not  protect  the  brain  from  incoming  impulses  which  excite  to  an 
exhausting  waste  of  energy;  while  gas-oxygen  anaesthesia,  on 
the  other  hand,  does  protect  the  brain  to  some  extent.  In  the 
second  place,  we  now  know  that  if  the  sensory  nerves  leading 
from  the  wounded  part  can  be  temporarily  blocked  (i.e.,  rendered 
incapable  of  carrying  nerve  impulses),  as  by  the  infiltration  of 
the  tissues  with  a  local  anesthetic,  then  no  exciting  stimuli  will 
reach  the  brain-cells  and  there  will  be  no  waste  of  energy  and 
no  shock. 

Further,  the  character  of  an  emotion  is  largely  determined 
by  memory.  Our  conscious  life  from  moment  to  moment  is  a 
mosaic  of  remembered  things  and  of  new  impressions  of  things 
that  are  happening.  New  impressions  call  up  old  experiences 
through  the  association  of  ideas,  and  our  resulting  action  and 
emotion  will  depend  upon  the  character  of  the  associations  that 
are  aroused.  These  associations  are  broadly  of  two  kinds,  those 
that  suggest  beneficial  effects  (bene-associations)  and  those  that 
suggest  harmful  effects  (noci-associations).  The  new  technic 
involves  the  avoidance  of  suggestions  or  associations  of  harm, 
and  for  the  description  of  such  a  technic  Dr.  Crile  has  coined  a 
new  word — anoci-association. 

II.  THE  TECHNIC  OF  ANOCI-ASSOCIATION 

Every  major  surgical  operation,  even  when  the  risk  is  small, 
is  an  ordeal  of  so  serious  a  character  that  few  men  or  women  can 
meet  it  without  considerable  emotional  stress.  It  is  not  true, 
of  course,  that  every  one  who  is  to  be  operated  on  is  seriously 
frightened.  On  the  contrary,  every  surgeon  knows  how  rare  it 
is  to  see  any  patient  yield  to  craven  fear,  and  he  is  an  almost 
daily  witness  of  examples  of  serene  and  unfaltering  courage  that 
have  never  been  overmatched  upon  the  field  of  battle.  The 
brave  are  able  to  overcome  fear  and  to  control  their  actions  in 
spite  of  it,  but  they  are  not  therefore  exempt  from  emotional 
stress  and  the  drain  which  it  involves  upon  the  vital  forces.  In 
ordinary  cases  this  is  not  perhaps  of  much  importance,  but  in 
critical  cases  it  may  be  a  decisive  factor  in  the  operative  hazard. 
There  is,  therefore,  nothing  fantastic  or  visionary  in  any  rational 
attempt  to  reduce  this  factor  as  far  as  may  be  possible.  That 
every  effort  should  be  made  to  prevent  the  shock-producing 
effect  of  actual  trauma  needs,  of  course,  no  argument  whatever. 

It  is  the  aim  of  the  anoci-association  technic  to  bring  under 


ANOCI-ASSOCIATION  233 

control  at  every  possible  point  these  two  factors  in  the  operative 
risk,  the  harmful  effects  of  emotion  and  of  trauma.  It  applies 
to  the  whole  period  of  a  patient's  surgical  experience,  from  the 
first  consultation  with  the  surgeon  up  to  final  recovery.  This 
period  may  be  divided  into  four  parts:  (1)  from  the  first  con- 
sultation to  the  time  of  entering  the  hospital;  (2)  from  the 
entrance  to  the  hospital  to  the  beginning  of  the  anaesthetic; 
(3)  the  anesthetic,  the  operation,  and  the  recovery  from  the 
anesthetic;  (4)  the  convalescence.  There  are  four  critical 
periods  when  the  mind  of  the  patient  is  particularly  susceptible 
to  harmful  suggestions:  (1)  the  first  contact  with  the  surgeon; 
(2)  the  first  entrance  to  the  hospital;  (3)  the  time  immediately 
before  the  operation,  when  the  patient  at  last  comes  face  to 
face  with  the  dreaded  ordeal;  (4)  the  time  when  consciousness 
returns  on  recovery  from  the  anaesthetic. 

As  Dr.  Crile  says:  "It  is  only  experience  and  a  sympathetic 
understanding  of  the  sensibilities  of  patients  that  enables  any 
surgeon,  at  the  time  of  diagnosis  and  recommendation  of  opera- 
tion, to  reduce  to  a  minimum  the  first  personal  contact.  The 
pre-operative  stay  in  the  hospital  can  be  made  least  harmful 
by  the  highest  degree  of  efficiency  on  the  part  of  the  nursing 
and  resident  staff  of  the  hospital,  and  by  considerate  attention 
to  the  details  on  the  part  of  the  operating  surgeon."  As  to  the 
fourth  period,  "inconsiderate  nursing,  rough  dressings,  and 
tactless  contacts  in  the  hospital  during  convalescence"  are  to 
be  avoided. 

The  technic  at  the  operation  itself  can  be  very  briefly  sum- 
marized. A  small  dose  of  morphine  and  scopolamine  is  given 
an  hour  and  a  half  or  two  hours  before  the  operation,  except,  of 
course,  in  the  very  young  or  very  old,  or  in  badly  handicapped 
patients.  Nitrous  oxide  with  oxygen  is  the  anaesthetic  employed, 
and  it  is  administered  by  a  trained  anaesthetist  (preferably  a 
woman,  in  Dr.  Crile's  opinion).  The  patient  is  carefully  handled 
and  placed  on  the  operating  table  in  proper  position  to  avoid 
back  strain,  preferably  on  a  warm  water  bed.  The  tissues  in  the 
field  of  operation  are  infiltrated  with  a  local  anaesthetic  solution 
(novocaine  1^00)  as  completely  as  if  the  operation  were  to  be 
done  under  local  anaesthesia  only.  In  abdominal  operations  the 
area  of  the  peritoneum,  which  is  incised  and  later  sutured,  is 
infiltrated  with  a  1-200  solution  of  quinine  and  urea  hydro- 
chloride,  which  has  the  property  of  producing  local  anaesthesia 


234  THE  PATIENT 

lasting  several  days.  The  object  of  this  is  to  minimize  post- 
operative pain  and  gas  distention  in  the  abdomen,  which  is  so 
common  after  abdominal  operations.  The  greatest  possible 
gentleness  in  the  manipulation  of  tissues  throughout  the  opera- 
tion itself  is  an  important  feature  in  the  technic.  The  patient  is 
closely  watched  during  recovery  from  the  anaesthetic,  and  verbal 
suggestion  is  made  early  to  the  dawning  consciousness  that  the 
ordeal  is  successfully  passed  and  that  all  is  well. 

The  psychic  shock  at  the  critical  period  when  the  patient 
faces  the  operation  in  the  immediate  present  is  of  special  impor- 
tance in  cases  of  exophthalmic  goitre,  the  symptoms  of  which 
have  a  curious  resemblance  to  those  of  fear.  In  such  cases  Dr. 
Crile  has  succeeded  in  avoiding  altogether  the  harmful  sugges- 
tions at  this  crisis  by  accustoming  the  patient  to  harmless  inhala- 
tions administered  each  morning  by  a  nurse  who  is  a  skilled 
anaesthetist,  the  patient  on  the  final  morning  passing  into  com- 
plete anaesthesia  without  knowing  that  the  day  selected  for  her 
operation  has  arrived.  Of  course  the  patient's  full  consent  has 
been  previously  obtained  that  the  operation  may  be  done  at  any 
time  that  the  surgeon  may  select. 

III.  THE  NURSE'S  PART  IN  THE  ANOCI-ASSOCIATION  TECHNIC 

Except  at  the  very  beginning,  the  nurse's  contact  with  the 
patient  corresponds  rather  closely  with  that  of  the  surgeon. 
During  the  whole  time  within  the  hospital,  except  at  the  opera- 
tion itself,  her.  contact,  particularly  with  woman  patients,  will 
be  even  more  close  and  intimate,  certainly  more  continuous,  than 
that  of  the  surgeon  himself.  At  the  critical  points  of  entrance 
into  the  hospital,  and  recovery  from  the  anaesthetic  more  depends 
upon  the  nurse  than  upon  the  surgeon. 

We  may  consider  the  conduct  of  both  surgeons  and  nurses  in 
relation  to  the  effect  produced  upon  the  mind  of  the  patient  under 
two  aspects.  The  first  is  general  and  concerns  the  atmosphere 
in  which  the  patient  finds  himself  upon  entering  the  hospital  and 
the  spirit  which  animates  each  unit  in  the  surgical  organization. 
This  atmosphere  and  this  spirit  are,  of  course,  simply  a  reflection 
of  the  quality  of  the  organization  itself,  and  are  not  assumed  or 
cultivated  with  any  reference  to  what  the  patient  may  think 
about  them.  Nevertheless  the  presence  of  the  right  atmosphere, 
the  character  of  which  may  perhaps  be  best  indicated  by  the  two 


ANOCI-ASSOCIATION  235 

words  efficiency  and  sincerity,  is  vital  for  good  anoci-association 
work  and  must  receive  due  consideration. 

The  second  aspect  referred  to  is  particular  and  personal,  since 
it  concerns  the  actual  conduct  of  surgeon  and  nurses  when  they 
come  in  contact  with  the  patient.  The  prime  requisites  of  right 
conduct  from  the  anoci-association  view-point  are  supreme  tact 
and  sympathetic  understanding  of  the  individual  patient.  We 
will  consider  the  general  aspect  first. 

What  qualities  and  what  attitude,  in  the  persons  into  whose 
hands  the  patient  has  committed  himself  in  the  face  of  a  trying 
ordeal,  will  make  the  strongest  impression  upon  his  mind  in  the 
way  of  encouragement  and  reassurance?  Not  sympathy;  a 
friendly  personal  interest  and  active  attention  to  matters  per- 
taining to  his  comfort  and  well-being  make  a  strong  appeal,  of 
course,  but  sympathy  alone  is  a  poor  comfort  in  the  presence 
of  danger.  A  passenger  on  a  storm-threatened  vessel  will  be  very 
little  helped  by  the  knowledge  that  the  captain  and  other  officers 
are  exceedingly  sorry  for  him.  What  he  wants  to  see  in  these 
men  are  evidences  of  disciplined  order,  keen  attention  to  every 
detail  of  the  situation,  and  a  serene  confidence  in  their  ability 
to  meet  any  emergency  that  can  arise.  It  is  the  same  in  the 
hospital;  the  impressions  which  the  mind  of  the  patient  should 
receive  are:  first,  that  of  a  coordinated  group  of  workers  (sur- 
geon, anesthetist,  internes,  nurses),  highly  trained,  familiar  with 
every  point  in  the  situation,  keenly  interested,  alertly  attentive 
to  their  several  duties,  and  working  together  with  machine-like 
precision;  second,  that  the  whole  purpose  and  attention  of  this 
disciplined  body  are  for  the  moment  directed  to  bringing  the 
patient's  own  case  to  a  successful  conclusion,  with  an  interest 
in  this  object  as  keen  as,  let  us  say,  that  of  a  crack  athletic  team 
to  win  a  championship  game. 

There  is  one  other  impression  that  the  patient  should  not 
fail  to  receive,  and  that  is  of  the  absolute  certainty  in  the  minds 
of  every  member  of  the  hospital  team  that  in  this  particular 
case  they  are  going  to  win,  i.e.,  as  regards  the  patient's  life  risk 
in  the  operation.  There  is  no  faking  about  this.  We  must  win, 
and  in  order  to  do  this  we  must  be  certain  of  winning  beforehand. 
That  is  the  first  rule  for  the  players  of  every  game  worth  while, 
either  in  the  field  of  sport  or  in  the  serious  affairs  of  life.  It  is  the 
doubters  who  lose,  they  and  sometimes  the  complacent  ones; 
ours,  however,  must  not  be  the  certainty  of  those  who  are  com- 


236  THE  PATIENT 

placent,  but  the  certainty  of  those  who  can  afford  to  take  no 
chances. 

We  have  used  the  words  efficiency  and  sincerity  in  summing 
up  this  first  or  general  aspect  of  anoci-association  work.  Sinr 
cerity  in  this  connection  does  not  mean,  of  course,  the  absence  of 
a  proper  reticence,  still  less  the  exercise  of  a  brutal  frankness  in 
what  we  say  to  a  patient.  What  is  meant  is  simply  the  absence 
of  shams  and  a  loyalty  to  the  patient's  interests  that  is  genuine 
and  unqualified. 

The  consideration  of  the  second  aspect,  that  which  relates  to 
the  management  of  the  individual  patient,  presents  considerable 
difficulties.  Few  general  rules  can  be  laid  down.  Each  patient 
indeed  is  a  separate  problem.  The  reasoning  and  methods,  for 
example,  which  are  applied  to  a  phlegmatic  woman  from  the  slums 
will  be  quite  different  from  those  which  should  be  employed  in 
the  case  of  a  highly-strung,  nervous  woman  accustomed  to  luxuri- 
ous surroundings.  It  is  in  this  consideration  of  each  patient  as 
an  individual  that  many  nurses  and  doctors  fail.  It  is  here  that 
the  exercise  of  supreme  tact  becomes  an  essential  part  of  the 
anoci-association  technic.  Tact  means  touch,  here  the  sensitive 
mental  touch  in  contact  with  the  mind  of  the  patient.  A  tactful 
person  recognizes  instinctively  certain  aspects  of  the  mental 
attitude  of  another  individual  which  are  not  openly  manifested; 
the  concealed  feelings,  as  of  distrust  or  antagonism,  the  suppressed 
emotion,  as  of  fear  or  hunger  for  sympathy  or  annoyance  at  some 
real  or  fancied  slight.  Tactful  conduct  adapts  itself  skilfully  to 
these  subtly  perceived  conditions  and  wins  its  way  against  all 
resistance,  even  from  the  most  stubborn  personality.  It  is  often 
said  that  tact  is  an  inborn  quality  and  cannot  be  acquired.  But 
while  there  is  much  to  justify  this  view,  it  may  be  pointed  out 
that  tactful  conduct  is  a  reflection  of  a  habit  of  mind,  the  habit 
of  putting  oneself  in  another's  place,  and  this  habit,  like  any  other, 
can  be  cultivated  and  acquired  by  determined  and  sustained 
effort. 

As  to  sympathy,  rightly  understood,  there  can  be  no  question 
of  its  value  and  importance.  An  unsympathetic  atmosphere 
begets  distrust.  It  is  true,  as  has  already  been  suggested,  that 
sympathy  in  the  sense  of  commiseration  or  compassion  is  of  little 
use  in  guarding  the  patient  from  those  harmful  associations  which 
we  wish  to  avoid.  Such  sympathy  is  doubtless  soothing  to  a 
tortured  mind,  but  it  carries  no  suggestion  of  security;  it  suggests, 


ANOCI-ASSOCIATION  237 

if  anything,  the  contrary.  Sympathy  that  is  effective  and  helpful 
is  not  emotional  but  intellectual;  its  office  is  to  understand,  not 
to  commiserate;  its  purpose  is  to  bring  the  person  who  is  its 
object,  by  the  light  of  a  clearer  knowledge,  to  a  view-point  cor- 
responding to  its  own.  If  the  object  aimed  at  is  to  be  attained, 
our  sympathetic  understanding  must  have  such  an  effect  upon 
the  patient's  mind  as  to  make  it  share  in  our  feeling  of  confidence 
in  the  methods  which  we  employ  and  our  own  certainty  in  the 
good  result. 

Both  before  and  after  entering  the  hospital  the  patient's  con- 
tact with  friends  and  acquaintances  is  a  source  of  noci-associations 
which  is  to  a  large  extent  beyond  our  control.  Some  people, 
because  of  ignorance  and  prejudice,  are  almost  incredibly  brutal 
and  tactless  in  what  they  say  to  a  patient.  On  the  other  hand, 
these  friends  are  often  our  most  helpful  supporters  in  bringing  a 
patient  to  operation  in  a  cheerful  and  confident  attitude  of  mind. 
Within  the  hospital  the  patient's  contact  with  other  patients 
may  be  the  means  of  arousing  the  emotion  of  fear.  In  the  free 
wards  of  a  hospital  (the  male  wards  particularly)  the  patients 
who  have  already  been  operated  on  sometimes  take  a  mischievous 
delight  in  initiating  the  newcomers  with  hair-raising  accounts 
of  their  own  experiences.  The  nurse  may  have  better  opportuni- 
ties than  the  surgeon  to  learn  of  and  counteract  the  hurtful  sug- 
gestions from  both  these  sources.  Patients  who  have  passed  the 
ordeal  can  do  much  to  help  us  if  we  can  secure  their  interest  and 
cooperation.  Proper  hospital  discipline  and  tactful  management 
on  the  part  of  nurses,  internes  and  surgeon  can  do  much  to  avert 
harmful  contacts  of  the  patient  with  friends  or  other  patients. 

With  regard  to  definite  rules  of  conduct,  only  a  few  suggestions 
of  a  general  character  can  be  given.  The  first  is  not  to  talk  too 
much.  The  nurse  should  say  as  little  as  possible  and  volunteer 
nothing  at  all  about  operative  risks.  In  the  first  place,  it  is  the 
duty  of  the  surgeon  to  impart  the  knowledge  to  which  the  patient 
is  entitled  in  regard  to  the  quality  of  danger  that  is  to  be  en- 
countered, and  all  such  questions  should  be  referred  to  him  for 
an  answer.  In  the  second  place,  overanxiety  in  insisting  upon  the 
absence  of  danger  may  have  an  effect  quite  opposite  from  that 
intended.  Mere  optimistic  assurances  carry  little  weight  with 
patients,  who  are  apt  to  regard  these  as  perfunctory  and  possibly 
insincere.  On  the  other  hand,  the  nurse  need  not  hesitate,  when 
questioned,  to  give  free  expression  to  her  own  confidence  that 


238  THE  PATIENT 

the  result  will  be  good  derived  from  her  personal  experience 
and  observation  and  from  a  just  pride  in  the  achievements  of  the 
organization  in  which  she  is  a  unit.  In  doing  this,  however,  it 
is  best  to  avoid  all  reference  to  anatomical  or  operative  technical 
details.  The  methods  of  surgery  can,  as  a  rule,  have  only  a 
morbid  interest  for  one  who  lacks  the  training  needed  to  see 
them  in  their  proper  setting  as  a  means  to  an  end,  and  they  are 
full  of  possibilities  of  harmful  suggestions  to  the  patient.  Perhaps 
the  most  difficult  achievement  in  conduct  will  be  found  in  main- 
taining such  a  proper  reticence  without  veering  from  the  straight 
path  of  sincerity  and  truth.  To  deceive  a  patient  deliberately 
is  neither  right  nor  fair  play  nor  justifiable  on  grounds  of  expedi- 
ency; for  if  once  a  suspicion  of  being  deceived,  or  that  knowledge 
of  important  matters  is  being  withheld,  has  found  lodgement,  it 
will  be  very  difficult  to  regain  the  confidence  that  has  been  lost. 
Sometimes,  indeed,  the  impulse  of  a  great  compassion  may  lead 
one  to  give  comforting  assurances  without  strict  regard  to  the 
truth,  but  this  practice  should  never  become  a  rule  of  conduct. 
Moreover,  since  a  reticence  that  is  too  obvious  may  have  the 
appearance  of  insincerity,  it  is  probably  better  that  all  discussion 
of  grewsome  details  or  other  distressing  matters  should  be  frankly 
forbidden  rather  than  that  shifty  attempts  at  evasion  be  made 
in  response  to  the  patients'  questions  about  them.  At  all  times 
every  effort  should  be  made  to  keep  the  brighter  side  of  the 
picture  in  the  focus  of  attention. 

The  moment  when  consciousness  returns  after  reaction  from 
anesthesia  has  been  mentioned  as  one  of  the  critical  periods  of 
emotional  stress.  Although  recovery  from  nitrous  oxide  and 
oxygen  anaesthesia  is  far  more  rapid  than  from  ether,  in  neither 
case,  of  course,  does  consciousness  return  all  at  once.  Recovery 
is  by  progressive  stages,  the  higher  mental  faculties  concerned 
in  the  exercise  of  reason  and  will  being  the  latest  to  awaken,  and 
meantime  all  the  harmful  associations  that  have  been  so  carefully 
silenced  and  controlled  may  return  with  unrestricted  sway. 
Before  the  heavy  eyelids  can  open  the  mind  gropes  blindly  in 
the  dark  for  the  broken  threads  of  memory,  and  the  first  recall 
of  the  actual  situation,  like  the  sudden  remembering  of  a  great 
trouble  on  waking  from  sleep,  is  apt  to  come  with  a  shock  that 
brings  potent  suggestions  of  uncertainty  and  doubt  as  to  the 
result  of  the  operation  with  a  corresponding  emotional  strain. 
The  preliminary  dose  of  morphine  and  scopolamine  has  an  un- 


ANOCI-ASSOCIATIOlSr  239 

doubted  calming  influence  upon  the  patient  both  at  the  beginning 
of  the  operation  and  at  the  time  of  the  recovery  from  the  anaes- 
thetic. The  effect  of  these  drugs  is  to  inhibit  emotion  and  mem- 
ory, but  this  does  not,  of  course,  alter  the  psychic  situation  at  the 
sudden  recollection  of  a  dreaded  ordeal,  with  its  attendant  pos- 
sibilities of  arousing  the  emotion  of  fear.  When  full  consciousness 
returns  the  patient  is  apt  to  ask  repeated  questions  about  the 
operation  and  to  be  not  very  easily  convinced  that  all  is  as  it 
should  be.  Since  it  is  almost  invariably  a  nurse  who  is  with  the 
patient  at  this  time,  upon  her  devolves  the  duty  of  giving  the 
assurances  needed  to  dispel  the  harmful  associations  that  may 
arise,  and  it  is  important  for  her  to  know  how  this  may  best  be 
done.  With  regard  to  this  point  Dr.  Crile  has  suggested  a  method 
which  is  of  unique  interest  and  value. 

It  appears  at  first  glance  like  utterly  ridiculous  folly  even  to 
try  to  think  of  a  way  to  tide  an  unconscious  patient  over  this 
crisis.  What  wizardry  can  we  conjure  up  to  control  the  mind 
in  sleep?  Yet  the  method  of  doing  this  is  very  simple  and  almost 
invariably  successful. 

In  sleep  all  paths  by  which  knowledge  reaches  us  from  the 
outer  world  are  obstructed,  but  not  all  equally  so.  Vision  is 
wholly  cut  off.  We  are  blind  in  sleep,  the  eye  cannot  receive 
and  convey  any  message  whatever  to  the  brain.  Not  so  the  ear; 
except  in  the  profoundest  sleep  this  avenue  between  the  brain 
and  the  world  without  is  never  wholly  blocked.  Our  dreams,  as 
every  one  knows,  are  often  affected  and  controlled  by  sounds 
that  do  not  waken  us.  A  sleeper  may  even  make  what  appear 
to  be  intelligent  movements  in  response  to  spoken  commands 
and  have  no  recollection  of  so  doing  when  he  wakes.  It  is  through 
the  ear,  therefore,  and  through  this  avenue  alone,  that  we  can 
reach  the  anaesthetized  patient,  before  consciousness  returns, 
with  a  message  of  comfort  and  reassurance. 

At  the  first  sign  that  the  patient  is  passing  from  profound 
unconsciousness  into  the  borderland  of  sleep,  a  change  in  the 
respiratory  rhythm,  or  a  movement  of  the  head  or  hand,  a  quiet, 
assured  voice  speaks  clearly  into  her  ear,  "  The  operation  is 
over  and  everything  is  all  right."  Again  and  again,  through  the 
slow  struggle  up  out  of  the  dark,  the  voice  repeats  its  message, 
always  in  clear,  deliberate  tones  and  with  the  simplest  phrasing. 
It  ceases  when  the  eyes  first  open  with  a  conscious  look. 

The  contrast  of  such  an  awakening  with  that  we  have  just 


240  THE  PATIENT 

described  is  curiously  interesting.  When  full  consciousness  re- 
turns, the  patient's  expression  is  not  one  of  pitiful  anxiety  and 
doubt,  but  rather  one  of  immense  relief.  Often  she  appears 
quite  happy  and  contented.  She  asks  no  questions;  she  feels  no 
need  of  asking,  for  she  knows  that  the  dreaded  ordeal  is  over 
and  that  all  is  well.  How  this  knowledge  came  to  her  she  can- 
not tell  you  and  will  be  puzzled  for  a  moment  if  you  ask  her, 
but  not  troubled  with  any  shadow  of  doubt.  Absolute  convic- 
tion is  in  her  mind,  a  certainty  like  that  of  intuitive  knowledge, 
and  she  accepts  it  gladly  and  without  question. 

Miss  Florence  Henderson,  anaesthetist  at  the  Mayo  Clinic, 
uses  the  same  method  of  verbal  suggestion  at  the  beginning  of 
the  administration  of  an  anaesthetic.  She  points  out  that, 
"  Suggestion  plays  an  important  part  in  the  induction  of  anaes- 
thesia." And,  "  The  assurance  of  the  anaesthetist,  when  the 
patient  is  in  the  subconscious  state,  that  he  is  all  right  and  that 
nothing  will  be  done  until  he  is  unconscious,  aids  markedly. 
The  mind  is  very  susceptible  to  suggestion  in  this  state,  and  the 
suggestion  that  everything  is  as  it  should  be  is  usually  accepted." 

In  Dr.  Crile's  clinic  at  the  Lakeside  Hospital  the  introduction 
of  the  anoci-association  technic  has  been  followed  by  a  reduction 
in  the  surgical  mortality  from  4.8  per  cent,  to  1.7  per  cent.  The 
diminution  of  post-operative  discomfort  has  been  especially 
notable. 

Finally,  it  should  be  pointed  out  that  whatever  disagreement 
there  may  be  among  surgeons  as  to  the  value  of  the  operative 
technic  advocated  by  Dr.  Crile,  the  use  of  nitrous  oxide  anaes- 
thesia, and  of  a  combination  of  local  and  general  anaesthesia, 
there  is  no  disagreement  at  all  about  the  importance  of  the 
general  principle  of  anoci-association;  and  as  Dr.  Bloodgood  has 
said,  we  cannot  safely  reserve  our  application  of  this  technic  for 
the  more  serious  cases.  The  mastery  of  any  technic  can  only 
be  acquired  by  incessant  practice,  and  we  must  employ  this  one 
in  all  cases  or  else  we  shall  fail  with  it  in  the  critical  ones  where 
the  need  for  it  is  imperative.  With  surgeons  and  nurses  alike 
the  application  of  the  principle  of  anoci-association  should  be- 
come a  fixed  habit  or  second  nature  in  the  personal  management 
of  all  patients,  no  matter  how  trivial  the  case. 


PART  V— THE  OPERATION 


CHAPTER  XIX 

THE  OPERATING  ROOM,  ITS  OUTFIT  AND  SUPPLIES 
I.  THE  OPERATING-ROOM  ORGANIZATION 

THE  operating  department  in  every  hospital  is  apt  to  be  a 
subject  of  special  pride  with  every  one  connected  with  it.  There 
is  perhaps  some  danger  that  this  very  proper  feeling  may  con- 
cern itself  too  much  with  the  imposing  but  comparatively  unim- 
portant material  aspects  of  the  equipment,  and  too  little  with  the 
real  essentials;  namely,  efficient  organization, conscientious  exact- 
ness in  every  small  detail  of  the  technic,  and  good  team  work  at 
the  operation  itself.  The  spotless  white  walls  and  floors,  the 
glittering  glass  furniture,  the  polished  battery  of  sterilizers,  the 
neat  array  of  shining  instruments,  the  many  ingenious  devices 
for  various  purposes, — all  these  make  an  attractive  picture,  but 
they  furnish  in  themselves  little  or  no  evidence  as  to  the  actual 
quality  of  the  work  that  is  being  done  in  the  department.  The 
whole  object,  both  of  the  equipment  and  the  organization,  is  to 
safeguard  the  patient  from  the  operative  dangers,  and  the  attain- 
ment of  this  end  depends  not  upon  the  showy  outfit  but  upon  the 
spirit  and  efficiency  of  the  workers  themselves. 

The  details  of  the  operating-room  organization  vary  consider- 
ably in  different  institutions.  The  persons  essentially  concerned 
with  the  work  of  the  operating  room  maybe  enumerated  as  follows : 

(1)  Surgeons  of  the  Attending  Staff,  the  Resident  Surgeon, 
and  sometimes  other  surgeons  not  connected  with  the  institution, 
who  operate  there  on  their  private  patients. 

(2)  Assistants,  usually  the  hospital  internes.     In  hospitals 
which  have  the  "  open  door  "  (that  is,  where  outside  surgeons 
are  allowed  to  operate  on  their  own  patients),  the  surgeons  may 
sometimes  bring  their  own  assistants  with  them.    Usually  a  first 
and  a  second  assistant  are  required  at  each  major  operation. 

(3)  Anaesthetists.    These  are,  as  a  rule,  graduates  in  medicine 
who  have  specialized  in  this  field.    They  are  appointed  and  paid 
by  the  institution  and  are  responsible  for  all  the  anaesthetics  given 
there.     They  give  to  the  internes,  and  sometimes  to  graduate 
nurses  who  desire  to  fit  themselves  for  this  work,  systematic 
instruction  in  the  administration  of  anaesthetics.    Some  surgeons 

243 


244  THE  OPERATION 

of  wide  experience  are  of  the  opinion  that  women  make  the  best 
anaesthetists,  and  there  is  reason  to  believe  that  this  may  become 
eventually,  to  some  extent  at  least,  one  of  the  nursing  specialties. 

(4)  The  operating-room  nurse  has  entire  charge  of  the  operat- 
ing rooms.     She  is  responsible  for  the  care  of  the  rooms  and 
equipment,    the   preparation   and   sterilization   of   the   various 
materials  used  in  an  operation,  and  the  training  of  the  pupil 
nurses  assigned  to  work  in  the  operating  room.    The  position  of 
operating-room  nurse  is  a  permanent  one  and  is  usually  filled 
by  a  graduate  nurse  who  has  had  special  training  and  experience 
in  the  work. 

(5)  Senior  assistant  nurses  who  have  had  a  month  or  more 
of  experience  in  the  operating  room.     In  a  very  active  service, 
where  several  operations  are  going  on  at  the  same  time  in  different 
rooms,  there  should  be  a  senior  assistant  nurse  in  immediate 
charge  of  each  separate  operating  room,  acting  under  the  direc- 
tion of  the  operating-room  nurse. 

(6)  Other  pupil  nurses  assigned  to  the  operating  room  for  a 
definite  period  during  the  course  of  their  training. 

(7)  Operating-room  orderlies,  who  do  the  heavy  work,  such 
as  lifting  the  patients,  cleaning  the  rooms  and  such  special  duties 
as  may  properly  be  assigned  to  them. 

It  is,  of  course,  the  surgeon  himself  who  is  chiefly  responsible 
for  the  results  of  his  operations,  but  these  results  depend  always 
in  large  measure  upon  the  quality  of  the  preparatory  technic, 
and  in  many  operating  rooms  a  number  of  surgeons  operate, 
some  of  whom,  at  least,  have  little  or  no  authority  over  the  oper- 
ating-room organization.  It  is,  therefore,  upon  the  operating- 
room  nurse  that  the  weight  of  responsibility  rests  for  efficient 
operating-room  administration,  and  it  is  in  many  cases  chiefly 
from  her  that  the  inspiration  comes  for  those  who  work  under 
her  direction.  Her  position  is  one  of  the  most  important  in  the 
surgical  department  of  any  hospital  and  is,  or  should  be,  one  of 
the  chief  prizes  of  the  nursing  profession.  Efficiency  in  operating 
organization  is  shown  by  a  perfect  and  absolutely  reliable  pre- 
paratory technic;  by  the  absence  of  vexatious  delays  in  the 
preparation  between  one  operation  and  another  that  is  to  follow 
it;  and  by  the  prompt  supply  of  such  needs  as  may  suddenly 
arise  in  an  emergency  during  an  operation.  The  final  mark  of 
efficiency  is  what  may  be  called  good  team  work  at  the  operation 
itself,  by  which  is  meant  that  each  person  does  his  own  part  at 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES  245 


246 


THE  OPERATION 


the  right  time  without  getting  in  the  way  of  any  one  else,  that 
the  surgeon  carries  out  each  successive  step  of  the  operation  in  a 
systematic  manner,  and  that  assistants  and  nurses  are  able,  so 
far  as  possible,  to  anticipate  his  needs. 

II.  THE  OPERATING  SUITE 

The  number  of  rooms  used  by  the  operating  department  may 
vary  from  three  or  four  to  ten  or  twelve.     Separate  rooms  are 


FIG.  80. — Sterilizing  room. 

necessary  for  four  different  uses:  (1)  the  operating  rooms  proper 
(Fig.  79),  (2)  the  sterilizing  room  (Fig.  80),  (3)  the  surgeons' 
dressing  and  preparatory  room,  (4)  the  supply  room.  In  addi- 
tion to  these,  separate  rooms  may  be  provided  in  the  operating 
suite  for  the  following  purposes :  nurses'  dressing  room,  separate 
preparation  rooms  for  surgeons  and  nurses  for  hand  cleansing, 
etherizing  rooms,  recovery  rooms,  instrument  room,  and  a  labora- 
tory room  for  the  rapid  examination  of  specimens.  In  a  hospital 
with  an  active  surgical  service,  there  should  be  at  least  two 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES 


247 


operating  rooms;  there  need  rarely  be  more  than  three  or  four 
except  in  the  largest  institutions.  The  essential  features  of  a 
good  operating  room  are  ample  space,  abundant  north  light, 
floors,  walls  and  ceilings  finished  with  some  material  that  is 
smooth,  non-porous,  and  water-proof,  and  absence  of  crevices 
or  corners  from  which  it  is  difficult  to  remove  dust.  In  the  other 


FIG.  81. — Hot-air  sterilizer. 

rooms  size  and  light  are  less  important,  but  all  should  be  so 
arranged  as  to  be  easily  cleaned. 

III.  THE  OPERATING-ROOM  FIXTURES 

These  comprise  the  arrangements  for  heating  and  for  arti- 
ficial lighting ;  the  plumbing  fixtures,  including  basins  and  sinks ; 
the  closets  and  the  steam  connections  for  the  various  sterilizers; 
the  lockers  in  the  dressing  rooms,  and  the  lockers  and  shelving 
in  the  supply  room;  and  finally  the  sterilizers. 

1.  The  Hot=air  Sterilizer. — This  is  much  used  in  the  labora- 
tory for  the  sterilization  of  glassware  andother  apparatus  (Fig.  81) . 
It  is  not  usually  a  part  of  the  furniture  of  the  operating  room. 
It  consists  of  a  double-walled  chamber  or  oven  with  a  door, 


248 


THE  OPERATION 


FIG.  82. — Autoclave. 


and  a  strong  gas  flame  underneath  so  arranged  that  the  heat 
enters  between  the  double  walls. 

2.  The  Autoclave  (Figs.  82-83).— This  is  also  a  double- walled 
chamber  with  a  door,  but  the  door  is  made  to  fit  air  tight,  and  to 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES 


249 


250  THE  OPERATION 

withstand  strong  pressure  from  within  the  chamber  without 
leaking.  Provision  is  made  for  turning  the  steam  at  will  into  the 
chamber  itself,  or  into  the  space  between  the  double  walls,  so  as 
to  apply  dry  heat  within  the  chamber  for  the  purpose  of  drying 
the  dressings  and  other  goods  after  they  have  been  sterilized. 
Provision  is  also  made  to  exhaust  air  from  the  chamber,  by  means 
of  a  valve,  when  the  steam  is  turned  into  it,  since  steam  in  an 


FIG.  84. — Instrument  sterilizer. 

air-filled  chamber  does  not  have  its  full  effect.  The  water  which 
produces  the  steam  may  be  contained  in  the  autoclave  itself, 
heat  being  then  applied  by  means  of  gas  jets.  In  all  large  hospitals, 
however,  the  steam  is  obtained  from  the  boiler-room  and  turned 
into  the  autoclave  by  means  of  valves. 

The  nurse  should  be  thoroughly  instructed  in  the  use  of  the 
autoclave.    So  many  different  forms  are  in  use  that  it  is  impos- 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES 


251 


sible  to  give  specific  instructions  here.  A  failure  to  employ  this 
apparatus  properly  means  a  failure  in  one  of  the  most  important 
parts  of  the  aseptic  technic.  Moreover,  the  danger  of  careless 
handling  of  high-pressure  steam  sterilizers  should  always  be 
remembered. 


FIG.  85. — Utensil  sterilizer. 

3.  The   Instrument  Sterilizer   (Fig.   84). — This  is  a  simple 
metal  container  of  suitable  size  and  shape  in  which  water  can 
be  boiled.    Heat  may  be  applied  by  means  of  .gas  or  of  steam  from 
the  boiler-room. 

4.  The  Utensil  Sterilizer  (Fig.  85). — This  is  a  larger  apparatus 
similar  to  the  instrument  sterilizer,  used  to  sterilize  basins  and 
other  large  objects  by  boiling  water. 


252 


THE  OPERATION 


ft! 


Fia.  86. — Water  sterilizers. 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES 


253 


5.  Water  Sterilizers  (Fig.  86). — These  are  large  tanks  in 
which  water  is  sterilized  by  means  of  steam  coils.  Two  tanks 
are  provided  in  order  that  both  hot  and  cold  sterile  water  may 
be  available  at  all  times. 

The  basins  for  hand  washing  are  so  arranged  that  the  hot 
or  cold  water  can  be  turned  on  or  off,  without  touching  anything 
with  the  hands,  by  means  of  levers  acted  on  by  pressure  with 


Fio.  87. — Operating  table. 

the  foot  or  knee,  the  mixture  of  hot  and  cold  water  being  delivered 
through  a  single  goose-necked  spigot  at  any  desired  temperature, 
so  that  the  hands  can  be  washed  in  a  running  stream. 

The  doctors'  dressing  rooms  are  provided  with  a  sufficient 
number  of  lockers  with  individual  keys.  The  supply  room  is 
fitted  with  lockers  and  shelving  with  glass  doors  for  the  storage 
of  supplies.  The  operating-room  nurse  should  have  a  master 
key  fitting  all  the  locks. 


254  THE  OPERATION 

IV.  THE  OPERATING-ROOM  FURNITURE  AND  UTENSILS 

The  furniture  in  the  operating  suite  is  all  made  of  enamelled 
iron  and  glass,  and  designed  in  the  simplest  possible  forms  in 
order  to  facilitate  cleaning.  In  the  operating  room  itself,  the 
operating  table  (Fig.  87)  is,  of  course,  of  first  importance.  There 
is  a  great  variety  of  operating  tables  in  use,  some  of  them  ex- 
tremely complicated.  In  all  the  object  aimed  at  is  to  facilitate 
the  placing  of  the  patient  in  the  various  positions  described  in 
another  chapter.  In  nearly  all  the  whole  table  can  be  tilted  so 
as  to  raise  or  lower  the  patient's  head.  Frequently  changes  of 
position  have  to  be  made  during  the  course  of  the  operating. 


Fia.  88. — Drums  filled  with  sterile  dressings  on  stand. 

The  nurse  should  familiarize  herself  with  the  mechanism  of  the 
table  in  use  in  the  operating  room  where  she  is  in  training.  The 
remaining  furniture  of  the  operating  room  should  be  restricted 
to  absolute  essentials.  A  table  for  instruments  and  dressings, 
a  stand  or  support  for  the  drums  containing  the  sterilized  dress- 
ings (Fig.  88),  basins  set  in  stands  for  hand-rinsing  solutions 
and  for  wringing  out  abdominal  pads  from  hot  salt  solution,  a 
stool,  a  small  table,  and  the  nitrous  oxide  gas  oxygen  apparatus 
for  the  anaesthetist,  and  two  or  more  stretchers  on  rubber -tired 
wheels  for  conveying  the  patient  between  his  bed  and  the  operat- 
ing table  constitute  the  articles  of  furniture  which  will  be  required 
in  every  operation. 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES  255 

The  utensils  needed  consist  of  a  number  of  glass  or  enamelled 
ware  dishes  and  basins  of  suitable  sizes  and  shapes  for  holding 
the  various  solutions  used  in  the  surgical  toilet,  and  for  the 
reception  of  pus  or  other  fluid  evacuations,  of  specimens  removed 
at  the  operation  and  of  soiled  sponges  and  dressings.  As  adjuncts 
to  the  operating  table  itself  a  pad  or  mattress  will  be  required 
for  the  patient  to  lie  on,  preferably  of 
rubber  and  distended  with  air,  in  any  case 
rubber  covered;  also  both  hard  and  soft 
cushions  in  several  shapes  and  sizes  to  sup- 
port the  patient's  head  and  other  parts 
of  his  body  as  occasion  may  require.  At 
times  the  surgeon  will  need  a  stool  to  sit 
on  and  at  other  times  a  footstool  to  stand 
on  for  convenience  in  some  special  manip- 
ulation. Infusion  of  fluid  into  the  rectum 
and  of  normal  salt  solution  under  the  skin 
or  into  a  vein  may  be  required  in  the  treat- 
ment of  shock  during  an  operation.  The 
apparatus  required  for  this  purpose  is 
known  as  an  irrigator  stand  (Fig.  89)  and 
consists  of  a  glass  receptacle  for  the  fluid, 
preferably  graduated,  having  an  opening 
at  the  bottom  to  which  five  or  six  feet  of 
rubber  tubing  is  attached.  The  other  end 
of  this  is  armed  with  a  suitable  nozzle 
or  hollow  needle.  The  glass  irrigator  is 
supported  on  a  stand  arranged  so  that  it 
can  be  raised  or  lowered  to  any  desired 
level.  Since  it  may  be  called  for  at  any 
time  on  short  notice  in  an  emergency,  the 
irrigator  with  its  tubing  and  needles  should 
always  be  sterilized  and  ready  for  instant 
use  at  every  major  operation.  A  rack  FlG"  8 
with  a  definite  number  of  hooks  on  which  to  hang  the  gauze  pads 
that  have  been  used  in  an  abdominal  operation  is  considered  an 
essential  piece  of  furniture  in  many  operating  rooms.  It  is  useful 
to  make  sure  that  the  pads  are  properly  counted,  in  order  that 
none  may  be  accidentally  left  in  the  abdominal  cavity.  The 
other  rooms  of  the  operating  suite  will  be  almost  bare  of  furniture. 
Space  must  be  found,  preferably  in  a  separate  room,  for  one  or 


256  THE  OPERATION 

more  instrument  cabinets,  made  of  glass  and  iron,  with  glass 
doors  and  shelves  on  which  the  instruments  are  arranged  in  order; 
also  for  a  glass  and  iron  shelf  rack  on  which  bottles  and  jars  con- 
taining various  materials  used  in  operative  work  may  be  placed. 
For  the  rest  a  few  glass-topped  tables  and  enamelled  iron  chairs 
or  stools  are  all  that  is  permissible. 

V.  THE  OPERATING-ROOM  SUPPLIES 

The  description  of  surgical  instruments,  of  the  methods  of 
preparing  the  various  materials  used  in  the  course  of  an  opera- 
tion, such  as  sutures,  ligatures  and  dressings,  and  the  preparation 
and  uses  of  the  different  solutions  employed  are  subjects  too 
extensive  to  be  included  here  and  must  be  reserved  for  separate 
consideration. 

To  begin  with  the  articles  required  for  the  surgical  toilet,  the 
first  is  soap.  It  is  probable  that  the  selection  of  the  particular 
kind  to  be  used  is  not  a  matter  of  very  great  importance.  The 
requisites  are  active  cleansing  powers  and  freedom  from  irritating 
properties.  The  finer  toilet  soaps  are  expensive  and  the  stronger 
kitchen  or  scouring  soaps  are  too  irritating  to  the  skin.  The 
official  green  soap  of  the  pharmacopoeia  is  most  commonly  used. 
It  must  be  diluted  with  boiling  water  for  the  double  purpose  of 
reducing  it  to  the  requisite  thinness  and  lessening  its  irritating 
properties.  The  prevention  of  irritation  of  the  skin  is  more 
important  than  the  use  of  strong  soaps.  Scouring  soap  and  even 
green  soap  are,  therefore,  objectionable.  A  neutral  soap  solution 
is  to  be  preferred.  Brushes  are  usually  employed  in  hand  cleans- 
ing, but  are  often  objectionable  on  account  of  the  injury  their 
constant  use  inflicts  upon  a  delicate  skin.  Thorough  scrubbing 
with  a  piece  of  soft  gauze  is  equally  efficient  and  far  less  irritating. 
The  use  of  anything  that  tends  to  roughen  the  skin  of  the  hands 
of  one  who  takes  part  in  an  operation  is  an  error  in  technic.  Nail 
cleaners  with  sharp  points  or  edges  are  to  be  avoided;  and  also 
any  solution  to  whose  irritating  properties  there  is  found  to  be 
an  individual  susceptibility. 

The  operating-room  dress  for  men  consists  of  a  two-piece  suit 
of  light-weight  cotton  material  for  which  the  street  clothing  is 
exchanged.  Over  this  a  rubber  apron  is  worn,  and  over  all  the 
operating-room  gown.  A  close-fitting  cap  of  cotton  material 
covers  the  hair.  The  mouth  and  nose  are  covered  with  a  mask 
to  prevent  droplet  infection  when  talking  near  the  wound.  The. 


OPERATING  ROOM:    OUTFIT  AND  SUPPLIES  257 

simplest  form  of  mask  consists  of  six  thicknesses  of  gauze  sewed 
into  a  square,  four  and  a  half  inches  on  the  side,  with  tapes  at  the 
corners  to  tie  round  the  head  and  neck.  Special  shoes  for  the 
operating  room  may  be  of  canvas  or  leather,  according  to  indi- 
vidual preference.  Rubber  gloves,  into  the  gauntlet  of  which 
the  sleeves  of  the  gown  are  tucked,  complete  the  toilet.  Buttons 
are  troublesome,  since  they  come  off  in  the  laundry.  Draw-strings, 
tapes  and  safety  pins  are  preferable  as  fasteners.  The  gowns  open 
at  the  back  and  are  fastened  with  tapes;  they  reach  below  the 
knee  and  are  best  made  with  detachable  sleeves  reaching  from 
above  the  elbow,  so  that  only  the  sleeves  need  be  changed  between 
clean  operations.  In  passing  from  an  infected  to  a  clean  case 
the  whole  gown  must  be  changed,  and  this  must  be  done  also  in 
passing  from  one  clean  case  to  another  if  detachable  sleeves  are 
not  used.  The  two-piece  suits  are  freshly  laundered  for  each  day, 
but  not  sterilized.  The  use  of  freshly  laundered  caps,  not  steril- 
ized, is  not  a  serious  break  in  technic.  Rubber  aprons  must  be 
sterilized  after  use  in  operating  on  an  infected  case.  Gowns, 
sleeves,  masks,  and  gloves  must  be  freshly  sterilized  for  each 
operation,  with  the  exception,  already  noted,  as  to  the  gown.  For 
women  the  gown  will  be  of  suitable  pattern  and  made  reaching 
to  the  feet.  The  caps  must  be  more  voluminous  and  fastened 
with  draw-strings  to  secure  them  over  the  hair.  Gowns  for 
visitors  are  sleeveless,  made  like  a  long  cape  to  cover  hands  and 
arms.  A  sufficient  number  of  these  various  garments  of  suitable 
sizes  is  kept  on  hand  and  a  freshly  laundered  supply  always 
ready.  Rubber  gloves  of  at  least  three  sizes  must  be  provided. 
A  glove  that  is  too  tight  becomes  painful  after  being  worn  for  an 
hour  or  two,  and  one  that  is  too  loose  is  a  source  of  awkwardness. 
Some  surgeons  have  gloves  manufactured  for  their  individual 
use  over  moulds  made  from  plaster  casts  of  their  own  hands, 
insuring  a  perfect  fit.  Gloves  are  easily  torn  or  punctured  at  an 
operation.  When  this  occurs  the  punctured  glove  must  be  at 
once  discarded  and  a  fresh  one  put  on.  A  glove  so  injured  can 
be  easily  patched  with  a  piece  cut  from  an  old  glove  and  applied 
over  the  defect  with  rubber  cement. 

For  the  protection  of  the  patient  on  the  operating  table,  the 
materials  required  are  blankets,  rubber  sheeting,  sheets  and 
towels.  Of  the  sheets  and,  particularly,  the  towels,  a  very 
abundant  supply  is  necessary.  The  so-called  laparotomy  sheet 
is  a  plain  sheet  with  an  opening  fourteen  inches  long  in  the  centre 
17 


258  THE  OPERATION 

of  the  sheet.  The  upper  end  of  the  opening  is  eighteen  inches 
from  the  top  hem  of  the  sheet.  The  edges  of  the  opening  are 
hemmed.  The  sheet  covers  the  patient's  whole  body  from  the 
neck  to  the  feet,  the  field  of  operation  being  exposed  through  the 
opening  in  the  centre  of  the  sheet.  The  gynaecological,  perineal 
or  lithotomy  sheet  is  made  in  the  form  of  two  loose  bags  shaped 
to  cover  the  patient's  feet  and  legs  when  in  the  lithotomy  posi- 
tion. The  remaining  portion  of  the  sheet  covers  the  lower  part 
of  the  abdomen  and  the  perineum.  A  twelve-inch  slit  exposes 
the  field  of  operation. 

Besides  the  rubber  gloves,  sheeting  and  aprons  already  de- 
scribed, there  are  a  number  of  other  articles  made  of  rubber 
which  find  a  place  among  the  operating-room  supplies.  Kelly 
pads  are  placed  under  the  patient's  hips  when  in  the  lithotomy 
position;  rubber  tubing  in  several  sizes  is  used  for  many  purposes; 
a  roller  bandage  made  of  pure  rubber  is  known  as  the  Esmarch 
bandage  and  is  used  to  compress  a  limb  for  the  purpose  of  con- 
trolling hemorrhage.  For  the  same  purpose  is  the  rubber  tourni- 
quet, a  piece  of  elastic  tubing  with  a  chain  and  hook  attached  to 
fasten  it  after  it  is  in  position.  This  should  always  be  applied 
over  several  thicknesses  of  toweling  wrapped  smoothly  about 
the  limb.  These  articles,  together  with  rubber  catheters,  stomach 
tubes  and  rectal  tubes,  should  perhaps  be  classed  with  the  instru- 
mental outfit.  To  prevent  deterioration  all  articles  made  of 
rubber  should  be  kept  dry,  dusted  with  talcum  powder  and  at  an 
even  temperature.  Extreme  cold  and  heat,  or  marked  changes 
of  temperature,  and  particularly  any  oily  substance,  cause  rapid 
deterioration  of  rubber. 

Glassware  -in  a  variety  of  forms  will  be  required,  including 
measuring  glasses  or  graduates,  holding  10  c.c.,  100  c.c.  and  1000 
c.c.;  bottles  and  jars  for  containing  chemicals;  and  empty  bottles 
and  jars  for  specimens.  Glass  tubing  in  various  sizes  and  forms 
is  used  for  many  purposes :  for  irrigator  nozzles,  to  connect  rub- 
ber tubing,  for  drainage  tubes  and  for  female  catheters.  Medicine 
glasses  and  drinking  glasses  will  be  often  needed.  Medicine 
droppers,  eye  droppers  and  glass  syringes  of  different  sizes  will 
be  occasionally  called  for.  The  graduated  glass  irrigators  have 
already  been  described.  Large  and  small  laboratory  flasks  of 
thin  glass  which  can  be  sterilized  will  be  needed  for  normal  salt 
solution.  Trays  and  small  dishes  for  various  purposes,  glass 
rods  and  microscopic  slides  and  test  tubes  should  be  included 


OPERATING  ROOM:     OUTFIT  AND  SUPPLIES  259 

in  the  outfit.  A  few  test  tubes  plugged  with  cotton  and  sterilized 
and  others  containing  culture  media  for  making  bacterial  cultures 
should  always  be  at  hand. 

A  rather  long  list  of  drugs  and  chemicals  will  be  kept  in  stock. 
Those  in  crystalline  or  powdered  form  will  include:  bichloride 
of  mercury,  boracic  acid,  permanganate  of  potash,  oxalic  acid, 
iodoform,  iodine,  bismuth  subnitrate,  carbonate  of  soda,  bicar- 
bonate of  soda,  oxide  of  zinc,  salicylic  acid,  common  salt,  silver 
nitrate,  novocaine.  Solutions  of  some  of  these,  of  appropriate 
formulae,  will  be  kept  in  stock,  and  others  will  be  made  up  as 
required.  Plaster-of-Paris  and  talcum  powder  will  also  be  needed. 

In  tablet  form  or  in  sterile  solution  in  sealed  glass  ampoules 
for  hypodermic  use  in  suitable  doses  there  will  be  needed:  mor- 
phia, atropia,  strychnia,  pituitrin,  cocaine,  epinephrin  (adrena- 
lin), strophanthin,  novocaine,  quinine  and  urea  hydrochloride, 
caffeine  and  sodium-benzoate.  Combination  tablets  of  some  of 
these  and  a  sufficient  variety  of  doses  of  each  of  them  will  be 
required.  The  list  of  drugs  in  liquid  form  will  include:  alcohol, 
carbolic  acid,  benzine,  tincture  of  iodine,  balsam  of  Peru,  aro- 
matic ammonia,  ether,  glycerine,  hydrogen  peroxide,  collodion, 
olive  oil,  whiskey,  amyl  nitrite  (in  "pearls"),  ammonia  water, 
rubber  cement.  In  semiliquid  form  vaseline,  green  soap,  glycrrite 
of  starch,  bone  wax  and  various  ointments  should  be  at  hand. 

Suppositories  containing  opium  and  certain  astringent  drugs 
are  frequently  used  after  operations  on  the  rectum.  It  is,  of 
course,  impossible  to  enumerate  all  the  special  formulae  that  are 
used  in  different  institutions. 

Of  the  various  woven  fabrics  included  in  the  operating-room 
supplies,  the  most  important  item  is  the  so-called  absorbent  or 
hospital  gauze.  There  will  be  several  grades  of  this,  some  of 
very  loose  weave  for  absorbent  dressings,  some  of  closer  weave 
for  use  in  making  such  articles  as  masks,  abdominal  packs  and 
roller  bandages^  Unbleached  muslin  will  be  used  for  making 
covers  for  dressing  material  when  being  sterilized,  retractors 
used  in  amputations,  roller  bandages  and  a  number  of  special 
forms  of  binders  and  bandages.  Crinoline  is  used  for  plaster-of- 
Paris  bandages  and  for  the  so-called  starch  bandage.  Cotton 
fibre  is  employed  in  several  forms.  The  ordinary  cotton  wadding 
of  commerce  has  comparatively  few  uses  in  the  operating  room. 
It  is  non-absorbent  because  of  the  oily  substance  which  it  con- 
tains. A  piece  of  it  cannot  be  made  to  sink  in  water.  It  is  some- 


260  THE  OPERATION 

times  used  where  elastic  pressure  is  desired  under  a  firm  bandage. 
Absorbent  cotton  is  the  same  material  from  which  all  the  oil 
has  been  abstracted.  A  piece  of  it  should  instantly  sink  to  the 
bottom  when  dropped  into  water.  Hospital  wadding  is  non- 
absorbent  cotton  made  in  the  form  of  sheets  glazed  on  both 
sides.  It  is  used  to  cushion  splints  and  to  pad  limbs  under  a 
plaster-of-Paris  bandage.  A  thick  felt,  such  as  harness  makers 
use,  is  employed  to  protect  bony  prominences  where  a  carefully 
fitted  plaster  splint  or  jacket  is  applied. 

A  number  of  miscellaneous  articles,  some  of  them  of  great 
importance,  remain  to  be  mentioned.  Adhesive  plaster  is  em- 
ployed to  fix  dressings  over  a  wound  and  has  an  astonishing 
variety  of  other  uses.  The  Z.  0.  (zinc  oxide)  plaster  is  least 
irritating  to  the  skin.  The  so-called  "  Janus  "  plaster,  faced  on 
both  sides  with  adhesive  material,  is  useful  to  prevent  bandages 
from  slipping.  Gutta-percha  tissue  is  employed  almost  uni- 
versally for  protecting  wound  surfaces  and  for  wrapping  gauze 
drains.  Silver  foil  is  used  in  many  operating  rooms  as  a  wound 
dressing,  particularly  after  skin  grafting. 

A  full  supply  of  material  for  splints  should  be  on  hand  in  the 
operating  room.  The  number  of  special  forms  of  splints  on  the 
market  is  too  large  to  be  described  in  detail.  The  forms  of  splint 
material  most  generally  useful  are  the  splints  of  woven  wire 
which  can  be  cut  and  bent  to  any  desired  size  and  shape  and  the 
splints  made  of  thin,  soft  wood.  A  form  of  wooden  splinting  of 
the  thinness  of  veneer  is  useful  to  incorporate  in  dressings  where 
a  firm,  even  pressure  or  a  certain  degree  of  rigidity  is  desired. 
It  comes  in  pieces  three  by  eighteen  inches.  Larger  and  heavier 
splints  of  wood  one-eighth  inch  in  thickness  are  supplied  which 
can  be  cut  to  any  size  or  shape  desired. 


CHAPTER  XX 

OPERATING  MATERIAL 
I.  CLASSIFICATION 

A  CONSIDERABLE  part  of  the  nurse's  time,  during  her  course 
of  training  in  the  operating  room,  will  be  taken  up  with  the 
preparation  of  the  various  materials  employed  in  the  course  of 
the  operation  itself  and  to  cover  and  protect  the  wound  after 
the  operation  until  the  completion  of  the  healing  process.  This 
work  of  preparation  is  of  fundamental  importance  for  the  surgical 
technic,  and  it  is  necessary  to  describe  it  with  some  exactness. 
It  must  be  remembered,  however,  that  the  practice  in  different 
institutions  in  the  preparation  of  operating  material  varies  con- 
siderably in  minor  points,  and  that  the  methods  given  here  are 
not  to  be  regarded  as  in  any  sense  exclusive,  for  the  form  in 
which  these  materials  are  made  up  is  largely  a  matter  of  personal 
preference  with  the  surgeon,  and  no  two  workers  will  ever  agree 
exactly  as  to  what  methods  and  means  are  the  best.  What  we 
shall  attempt  to  do  in  this  chapter  is  to  make  clear  the  purpose 
for  which  these  articles  are  used  and  to  describe  some  of  the 
methods  of  preparing  them  that  are  of  proved  efficiency. 

The  things  which  ordinarily  come  in  temporary  contact  with 
the  wounded  tissues  in  the  course  of  an  operation  are  (1)  the 
gloved  hands  of  the  surgeon  and  his  assistants,  (2)  the  instru- 
ments which  he  employs,  (3)  pieces  of  absorbent  gauze  or  cotton 
made  up  into  convenient  shapes  and  sizes.  These  latter  articles 
serve  three  distinct  purposes:  (1)  to  keep  the  wound  "  dry" 
(that  is,  to  soak  up  blood,  pus  or  other  fluid  which  tends  to  fill 
the  wound  and  obscure  the  surgeon's  view  of  the  field  of  opera- 
tion) ;  (2)  to  push  to  one  side  any  tissue  or  organ  that  tends  to 
get  in  the  surgeon's  way  and  hold  it  there  for  the  time  so  that  it 
will  not  obstruct  his  view  or  his  work;  (3)  to  protect  surrounding 
parts  from  contamination  with  septic  material  when  a  localized 
infection  is  being  dealt  with. 

Any  one  of  these  things  (gloves,  instruments,  gauze)  may 
become  a  source  of  infection  in  a  clean  wound  by  conveying 
septic  bacteria  into  it,  as  a  result  of  imperfect  methods  of  sterili- 
zation or  of  carelessness  in  handling  them  after  sterilization,  and 

261 


262  THE  OPERATION 

when  this  occurs  we  speak  of  it  as  "  contact  infection."  There 
are  other  materials  which  come  in  contact  with  the  wounded 
tissues  and  remain  in  contact  with  them  until  the  first  dressing, 
or  for  a  longer  time,  or  even  permanently.  The  most  important 
members  of  this  class  are  drains,  sutures  and  ligatures.  When 
infection  from  any  of  these  possible  sources  occurs  it  is  known 
as  "  implantation  infection." 

Materials  used  to  cover  and  protect  the  wound  are  known 
as  dressings,  and  are  put  up  in  a  great  variety  of  forms.  They 
are  usually  made  of  absorbent  gauze,  although  cotton  and  occa- 
sionally other  materials  are  also  used.  These  dressings  are  also 
possible  but  less  dangerous  sources  of  wound  infection. 

Other  articles,  such  as  adhesive  straps,  bandages  and  binders, 
serve  the  purpose  of  holding  the  dressings  in  place.  These*  need 
not  be  sterilized,  but  they  must,  of  course,  be  fresh  and  clean. 

II.   MATERIALS  WHICH  COME   INTO   TEMPORARY   CONTACT 
WITH  THE  WOUND 

1.  Sponges. — Sea  sponges  were  used  in  operations  in  the 
pre-aseptic  era,  but  had  to  be  discarded  because  they  could  not 
be  kept  clean.  The  name  is  retained  for  the  pieces  of  gauze  or 
cotton  that  are  now  used  for  the  same  purpose. 

Large  crushed  sponges  are  made  of  gauze  18  inches  square. 
The  raw  edges  are  tucked  under  and  the  gauze  crushed  with  the 
hand. 

Small  crushed  sponges  are  made  of  gauze  9  inches  square 
prepared  in  the  same  way.  These  latter  are  used  as  stick  sponges 
or  "  sponges  on  a  stick,"  by  which  is  meant  that  the  sponge  is 
caught  by  the  blades  of  a  long-handled  clamp  and  used  to  sponge 
out  the  bottom  of  a  deep  cavity. 

A  very  convenient  form  of  sponge  is  the  folded  strip  sponge. 
It  is  made  from  a  piece  of  gauze  18  inches  long  and  10  inches 
wide.  One  end  should  be  selvage  or  folded  in  one  inch  to  secure 
an  end  free  from  ravels.  The  gauze  is  folded  lengthwise,  bringing 
each  long  edge  to  the  centre  of  the  piece.  It  is  then  folded  once 
again  lengthwise.  This  gives  a  strip  of  folded  gauze  17  inches 
long  and  2J/2  inches  wide,  with  no  raw  edge  except  at  one  end; 
this  end  is  held  between  the  left  thumb  and  index  finger;  the 
index,  middle  and  ring  fingers  are  placed  together  closely,  the 
strip  is  wrapped  about  the  three  fingers  up  to  within  two  inches 
of  the  selvage  edge;  and  the  end  is  folded  down  diagonally  toward 


OPERATING  MATERIAL  263 

the  tips  of  the  fingers  and  tucked  under  the  roll.  The  sponges 
are  used  in  this  form  at  the  operation  and  can  also  be  quickly 
unrolled  when  a  long,  narrow  strip  is  needed  to  sponge  out  a 
deep  cavity. 

A  small  wad  of  cotton  wrapped  in  a  three-inch  piece  of  gauze 
and  tied  with  thread  is  a  useful  and  economical  form  for  use  in 
free  sponging  or  on  a  stick. 

Small  pledgets  of  cotton  rolled  into  balls  are  desirable  in 
some  operations  on  the  brain  where  the  tissues  must  be  handled 
very  delicately. 

2.  Packers  or  Laparotomy  Sponges. — These  are  also  known 
as  tape  sponges.  They  are  used  in  operations  within  the  abdomen 
to  keep  the  intestines  out  of  the  way  and  to  protect  them. 

Large  tape  sponges  are  made  as  follows.  Cut  the  gauze 
from  the  bolt  in  fifty-inch  lengths.  Use  the  full  width  of  the 
gauze  doubled  once  lengthwise.  Turn  the  ends  in  one  inch  to 
secure  smooth  edges;  bring  the  ends  together  and  sew  across  top 
and  sides;  at  one  corner  sew  a  ten-inch  length  of  tape,  preferably 
black  in  color.  This  gives  a  strip  of  four  thicknesses  of  folded 
gauze,  free  from  raw  edges,  twenty-five  inches  long  and  eighteen 
inches  wide.  This  size  is  very  convenient  to  pack  off  inlcstines 
during  the  removal  of  large  tumors.  The  tape  is  kept  outside 
the  abdominal  cavity  and  fastened  with  a  clamp  at  its  free  end 
to  prevent  its  being  accidentally  left  in  the  abdomen.  The  safe- 
guards against  this  inexcusable  happening  cannot  be  too  numer- 
ous or  too  carefully  adhered  to,  for  it  is  surprisingly  easy  to  over- 
look even  a  large  sponge  in  the  abdominal  cavity. 

Medium  tape  packers  are  made  from  twenty-four  inch  lengths 
of  gauze.  After  turning  raw  edges  in  one  inch  at  each  end,  the 
gauze  (already  doubled  once  on  bolt)  is  folded  lengthwise  in 
three  folds;  the  ends  and  side  are  sewed,  and  a  tape  is  sewed  to 
one  corner.  This  gives  a  strip  of  six  thicknesses  of  gauze  six 
inches  wide  and  twenty-two  inches  long.  Three  smaller  sizes 
of  packers  are  made  in  a  similar  manner  to  measure  when  finished 
six  by  six  inches,  four  by  four  inches,  and  two  and  a  half  inches 
by  two  and  a  half  inches.  The  smallest  size  is  not  often  used, 
but  is  very  convenient  at  certain  times.  At  the  Mayo  clinic 
three  sizes  of  packs  are  used,  (1)  4x8  inches,  (2)  5  inches  by  3 
yards,  (3)  3  inches  by  2  feet.  The  latter  are  used  for  packing 
about  the  gall-bladder.  All  are  made  of  eight  thicknesses  of 
gauze,  with  hemmed  edge  and  tape  at  the  corner. 


264  THE  OPERATION 

3.  Retractors  or  retractor  bandages  are  used  in  amputations 
to  hold  the  skin  and  muscle  flaps  out  of  the  way  while  the  bone 
is  being  divided  with  the  saw.  They  are  made  of  two  thicknesses 
of  unbleached  muslin,  twenty  inches  long  and  eight  inches  wide. 
The  bandage  is  split  for  two-thirds  of  its  length  into  either  two 
or  three  tails  and  the  edges  stitched  together.  The  two-tailed 
form  is  used  in  amputations-  of  the  upper  arm  or  thigh  and  the 
three-tailed  form  for  amputations  of  the  forearm  or  leg  where 
there  are  two  bones  to  be  divided. 

III.   MATERIALS   WHICH   ARE   TO   REMAIN   IN   THE   WOUND 
FOR  A  TIME  OR  PERMANENTLY 

1.  Sutures  are  stitches  used  to  hold  the  divided  tissues 
together  so  that  they  may  heal  in  the  proper  position.  All 
sutures  except  those  uniting  the  skin  or  mucous  membrane  remain 
permanently  in  the  wound.  Skin  stitches  are  usually  removed 
at  the  first  dressing  on  the  fourth  to  the  ninth  day  after  the  opera- 
tion. When  each  stitch  is  tied  separately  and  the  threads  cut 
short  the  suture  is  called  an  interrupted  suture.  A  continuous 
suture  is  one  where  the  tissues  are  sewn  together  in  the  ordinary 
way  with  a  long  thread  and  only  the  first  and  last  stitches  are 
tied.  Deep  or  buried  sutures  are  those  which  are  taken  in  any 
of  the  tissues  under  the  skin.  Sutures  are  of  two  kinds  as  regards 
the  material  of  which  they  are  composed:  (1)  those  made  of 
thread  or  wire  which  will  remain  permanently  in  the  tissues  or 
(when  in  the  skin  or  mucous  membrane)  will  be  cut  and  removed 
at  a  later  time,  and  (2)  those  made  from  animal  substances 
which  will  hold  the  tissues  in  place  while  the  healing  process  is 
going  on  and  then  will  become  gradually  absorbed.  For  the  latter 
class  of  sutures  and  ligatures  two  different  materials  are  employed. 
(1)  Catgut,  so-called,  is  the  same  material  that  is  used  for  violin 
strings,  except  that  for  surgical  uses  much  smaller  sizes  are 
selected.  It  is  made  from  the  fibrous  coat  of  the  intestines  of 
sheep  cut  into  strips  and  twisted.  The  word  catgut  is  supposed 
to  be  a  corruption  of  "  kitgut,"  kit  being  an  old  name  for  a  small 
violin.  (2)  The  material  known  as  kangaroo  tendon  consists 
of  strands  of  varying  thickness  separated  from  the  strong  tendi- 
nous bundles  found  in  the  tail  of  the  kangaroo. 

The  sterilization  of  these  materials  presents  a  problem  of 
peculiar  difficulty.  The  strength  and  pliability  of  sutures  de- 
rived from  animal  tissues  are  rapidly  destroyed  under  the  influence 


OPERATING  MATERIAL  265 

of  high  temperature  applied  in  the  ordinary  way.  Catgut,  from 
the  nature  of  its  origin,  is  almost  certain  to  have  embedded  in 
its  strands  some  of  the  bacteria  contained  in  the  intestinal  canal, 
and  among  these  are  not  infrequently  found,  particularly  in  the 
domestic  animals,  the  spores  of  anthrax  and  tetanus  bacilli, 
which  are  highly  resistant  to  every  method  of  sterilization.  Cat- 
gut was  doubtless  sometimes  the  cause  of  infection  in  wounds  in 
the  early  days  of  its  use,  owing  to  the  crude  methods  employed 
in  its  preparation,  and  it  may  become  a  source  of  danger  even 
now  through  lack  of  proper  care  or  the  use  of  an  imperfect  method 
of  sterilization.  At  the  present  time  we  have  available  a  number 
of  processes  whereby  catgut  can  with  certainty  be  made  sterile 
without  impairing  its  desirable  qualities.  Some  of  these  are 
described  below.  The  most  reliable  methods  are,  however,  so 
difficult  and  exacting  that  many  institutions  prefer  to  purchase 
their  catgut  prepared  and  sterilized  ready  for  use  from  commercial 
houses  which  make  a  specialty  of  this  work.  The  catgut  and 
kangaroo  tendon  supplied  by  these  firms  come  in  small  coils  of 
convenient  size  placed  in  glass  tubes  with  alcohol  and  hermeti- 
cally sealed.  When  this  prepared  catgut  is  used  the  only  further 
preparation  necessary  is  to  sterilize  the  outside  of  the  tube  by 
boiling  with  the  instruments.  The  tubes  are  scratched  with  a 
file  to  facilitate  breaking.  To  break  a  tube  the  instrument  nurse 
wraps  it  in  sterile  gauze  and  bends  it  in  a  direction  away  from  the 
file  mark.  The  alcohol  in  the  tube  serves  the  double  purpose 
of  acting  as  a  preserving  fluid  and  of  demonstrating  that  the 
tube  is  actually  sealed.  A  small  crack  in  a  tube,  or  an  almost 
invisible  opening  sometimes  left  at  the  point  of  sealing,  may 
escape  notice,  but  if  either  is  present  the  alcohol  will  rapidly 
evaporate,  and  such  a  dry  tube  must  always  be  discarded. 

The  materials  for  non-absorbable«  sutures  are  thread,  wire 
(of  silver  or  other  metal),  the  so-called  silkworm-gut,  and  horse- 
hair. Thread  used  for  sutures  is  either  silk  or  linen,  usually 
dyed  black,  although  white  silk  and  linen  in  the  natural  color 
are  much  used.  The  finest  size  compatible  with  sufficient  strength 
is  to  be  preferred.  For  ordinary  use  No.  A  to  No.  C  black  sewing 
machine  twist  or  surgeons'  iron  dyed  silk  (No.  2),  and  tight 
twisted,  iron-black  Irish  linen  (Nos.  25,  35,  and  50)  are  suitable. 
Linen  thread  impregnated  with  celloidin  to  make  it  non-permeable 
is  known  as  Pagenstecher's  linen.  The  thread,  whether  silk  or 
linen,  is  cut  into  two-yard  lengths,  wound  on  glass  spools  and 


266  THE  OPERATION 

sterilized  in  the  steam  sterilizer  with  the  dressing  materials  or 
by  boiling  with  the  instruments.  For  suturing  arteries  and  veins 
the  finest  silk  obtainable  is  required,  prepared  in  a  special  manner 
described  below. 

The  so-called  silkworm-gut  is  really  composed  of  the  same  sub- 
stance as  silk  thread.  This  is  the  secretion  which  the  silkworm 
spins  into  a  fine  filament  in  making  its  cocoon.  The  "  gut  "  is 
made  by  killing  the  worm  when  ready  to  spin  and  drawing  out 
the  silk  in  the  form  of  a  coarse  strand.  It  is  a  stiff,  wire-like 
material,  looking  like  spun  glass,  is  very  strong  and  is  now  used 
principally  as  a  "  tension  "  suture  in  closing  abdominal  wounds. 
It  is  sterilized  by  boiling.  Horsehair  is  not  much  used  as  a 
suture  material  at  the  present  time,  and  only  for  skin  stitches. 
It  is  prepared  by  washing  in  soap  and  water  and  in  ether  and 
sterilized  by  boiling  for  ten  minutes  in  one  per  cent,  soda  solution. 
Silver  or  other  wire  when  used  as  a  suture  material  is  wound  in 
small  coils  and  sterilized  with  the  instrumental  outfit. 

2.  Ligatures. — These  are  used  for  controlling  hemorrhage  by 
tying  around  the  bleeding  vessel  or  around  a  pinch  of  tissue  held 
by  a  "  clamp  "  at  the  bleeding  point.  The  materials  used  are 
silk  or  linen  thread  and  catgut  of  the  same  sizes  and  prepared  in 
the  same  way  as  that  used  for  sutures.  Catgut  is  always  to  be 
preferred  for  this  purpose  in  suppurating  wounds,  and  is  also 
used  by  the  majority  of  surgeons  at  the  present  time  as  the  liga- 
ture material  of  choice  in  clean  wounds.  Silk  or  linen  is,  however, 
preferred  for  ligating  large  arteries  as  giving  greater  security 
against  secondary  hemorrhage.  Catgut  when  wet  becomes  soft 
and  easily  stretched  and  the  knots  are  apt  to  slip.  In  the  use  of 
any  ligature  material  the  finest  threads  compatible  with  sufficient 
strength  are  to  be  preferred.  Repeated  boiling  or  steaming 
makes  any  thread  brittle,  and  silk  or  linen  ligatures  should  never 
be  resterilized  for  use  more  than  once. 

A  few  surgeons,  and  some  of  them  among  the  most  eminent 
in  the  profession,  are  very  strongly  of  the  opinion  ( that  catgut 
should  not  be  used  as  a  ligature  or  suture  material  except  in  the 
presence  of  septic  infection.  Where  sepsis  is  already  present 
the  use  of  absorbable  ligatures  is  necessary  because  a  foreign 
body  in  a  septic  wound  tends  to  prolong  suppuration  indefinitely, 
whereas  a  sterile  foreign  body  in  a  clean  wound  does  no  harm. 
It  is  not  proper  for  the  nurse  to  become  a  partisan  in  any  matter 
where  there  is  a  difference  of  opinion  among  surgeons  in  regard 


OPERATING  MATERIAL  267 

to  the  technic,  but  it  may  be  well  to  state  briefly  the  objections 
to  the  use  of  catgut,  in  order  to  emphasize  the  necessity  of  care 
in  its  preparation.  The  objections  as  summarized  by  Dr.  Halsted 
are  "  the  relatively  high  cost  of  catgut,  its  bulkiness,  the  incon- 
veniences attending  its  use  and  sterilization,  its  inadequacy,  the 
uncertainty  as  to  the  time  required  for  its  absorption,  and  the 
reaction  which  it  excites  in  the  wound."  Catgut,  particularly 
in  the  larger  sizes,  is  a  source  of  slight  but  distinct  irritation  in  a 
wound.  The  best  manufacturers  very  properly  urge  that  sur- 
geons should  use  by  preference  smaller  sizes  than  now  commonly 
employed.  This  irritating  property  is  doubtless  responsible 
for  the  fact  that  few  now  use  cat  gut  for  skin  stitches.  As  stated 
above,  catgut  is  thought  by  many  surgeons  to  be  an  unsafe 
ligature  material  for  large  arteries,  since  the  bite  of  the  tie  may 
become  loosened  by  softening  and  stretching  of  the  strand,  and 
an  ordinary  double  knot  is  apt  to  slip.  The  absorption  of  catgut 
is  accomplished  through  the  dissolving  action  of  ferments  in  the 
tissue  juices  and  by  phagocytosis,  and  this  process  is  a  slow  one. 
In  cases  reoperated  on,  a  catgut  knot  may  often  be  found  still 
unabsorbed  weeks  or  months  after  it  was  put  in  place.  With  an 
aseptic  technic  that  is  up  to  the  proper  standard  no  trouble 
need  be  feared  from  silk  or  linen  sutures  and  ligatures. 

3.  Methods  of  Preparing  Catgut. — If  only  the  surface  of  a 
strand  of  catgut  needed  to  be  sterilized  the  problem  would  be  a 
comparatively  simple  one,  but  unfortunately  in  the  process  of 
manufacture  septic  and  other  bacteria  are  quite  certain  to  become 
embedded  in  the  centre  of  the  strand  and  may  there  retain  their 
vitality  for  a  considerable  time.  The  most  serious,  although 
fortunately  not  a  very  frequent,  danger  arises  from  the  presence 
of  spores  of  the  tetanus  bacillus.  This  organism  is  commonly 
found  in  the  intestinal  contents  of  the  domestic  animals,  including 
the  sheep,  and  there  is  always  a  possibility  that  catgut  may 
contain  its  spores.  The  method  of  sterilization  must,  therefore, 
be  sufficient  to  destroy  with  certainty  this  most  resistant  organ- 
ism. Of  the  several  methods  of  sterilization  previously  described 
it  is  obvious,  in  the  first  place,  that  we  are  debarred  from  the 
use  of  one,  namely,  moist  heat  in  any  form,  since  this  will  so 
soften  and  weaken  the  catgut  as  to  render  it  useless.  There  is, 
however,  a  partial  exception  to  this  in  the  case  of  catgut  hardened 
in  formalin. 

Chemicals  in  watery  solution  are  unavailable  for  the  same 


268  THE  OPERATION 

reason,  and  the  strand  is  found  to  be  exceedingly  resistant  to 
alcoholic  solutions,  so  that  bacteria  embedded  in  the  centre  of 
the  thicker  strands  will  remain  unaffected,  even  after  immersion 
for  a  long  time  in  an  alcoholic  solution  of  a  powerful  disinfectant. 
A  long  strand  of  catgut  so  prepared  may  be  placed  in  culture 
media  and  incubated  at  a  suitable  temperature  for  some  days 
without  any  growth  resulting,  but  if  the  same  strand  be  cut  into 
quarter-inch  lengths  an  abundant  growth  will  follow.  This  fact 
has  been  repeatedly  demonstrated  in  the  case  of  catgut  prepared 
in  iodine  solution  at  the  laboratory  of  the  Michael  Reese  Hospital. 
Gaseous  disinfectants  will  not,  of  course,  penetrate  a  catgut 
strand.  There  remains,  therefore,  only  dry  heat  to  be  considered, 
and  for  this  a  much  higher  temperature  is  required  than  in  the 
case  of  moist  heat;  150°  C.  or  302°  F.  for  one  hour  is  the  mini- 
mum requirement  for  sterilization  by  dry  heat.  Now  moist 
heat  means  not  heat  in  any  liquid  but  heat  in  the  presence  of 
water.  Dry  heat  means  not  heat  in  dry  air  necessarily  but  heat 
in  the  absence  of  water.  Boiling  in  alcohol,  therefore,  is  an 
application  of  dry  heat.  The  boiling  point  of  alcohol  in  the  open 
air  is  170°  F.  Alcohol  boiled  under  fifteen  pounds  pressure  in  the 
steam  sterilizer  may  give,  at  the  most,  a  temperature  of  250°  F., 
far  below  the  requisite  point.  For  the  proper  application  of 
dry  heat,  therefore,  we  need  some  material  which  will  not  affect 
the  catgut  and  which  has  a  boiling  point  sufficiently  high  to  allow 
a  temperature  of  300°  F.  to  be  reached.  This  is  accomplished 
by  the  use  of  some  of  the  oily  hydrocarbons.  Two  of  the  methods 
here  given  are  based  on  this  principle. 

Two  varieties  of  catgut  are  used,  known  as  "  plain  "  and 
"  chromicized."  The  latter  has  been  chemically  treated  by  a 
process  similar  to  one  of  the  methods  used  in  tanning  leather,  the 
object  being  to  cause  delay  in  the  process  of  absorption.  Thus 
the  manufacturers  will  furnish  "  ten/'  "  twenty,"  or  "  thirty 
day  "  catgut.  The  rate  of  absorption  varies,  however,  with  the 
character  of  the  tissues  in  which  the  catgut  is  used.  Absorption 
in  skin  and  muscle  is  slow,  in  serous  or  mucous  membranes  it  is 
extremely  rapid.  The  preparation  of  plain  catgut,  preliminary 
to  its  sterilization,  consists  in  immersion  in  ether  for  several  days 
and  then  in  alcohol,  the  object  being  to  remove  any  fatty  material 
that  may  be  present,  for  this,  if  allowed  to  remain, tends  to  weaken 
the  catgut  under  the  influence  of  a  high  temperature.  Chromi- 
cized catgut  has  been  first  treated  with  ether  and  alcohol  as  above 


OPERATING  MATERIAL  269 

and  then  placed  in  a  solution  of  bichromate  of  potash,  six  grains 
to  the  pint  of '95  per  cent,  alcohol,  or  in  a  4  per  cent. '  aqueous 
solution  of  chromic  acid  for  twenty-four  to  thirty-six  hours. 

First  Method. — Dry  heat  (method  of  Reverdin).  The  catgut 
is  cut  into  eighteen-  to  thirty-inch  lengths  and  made  into  coils 
about  the  size  of  a  silver  quarter.  The  coils  are  strung  on  an 
asbestos  thread  and  suspended  in  a  double-walled  oven  in  such  a 
manner  that  they  do  not  come  in  contact  with  the  metallic  walls 
or  floor  of  the  oven.  The  temperature  is  gradually  raised, 
through  a  period  of  several  hours,  until  it  reaches  150°  C  (302°  F.), 
and  maintained  at  that  level  for  one  hour.  Close  attention  is 
necessary  in  carrying  out  this  method,  or  the  catgut  is  likely  to 
be  brittle.  At  least  two  hours  should  be  consumed  in  gradually 
raising  the  temperature  to  the  desired  point. 

Second  Method. — Dry  heat  sterilization  in  cumol  (Kronig's 
method).  On  the  first  day  the  coils  are  placed  in  the  dry  oven 
in  the  manner  already  described  and  the  temperature  gradually 
raised  to  116°  C.  (240°  F.)  and  maintained  at  that  level  for  one 
hour.  On  the  second  day  the  strands  are  immersed  in  cumol  and 
heated  very  gradually  up  to  155°  C.  (310°  F.),  at  which  tempera- 
ture they  are  kept  for  two  hours.  An  asbestos -lined  kettle  is 
used.  An  iron  basin  filled  with  dry  sand  is  placed  over  a  powerful 
gas  flame  and  the  kettle  partly  embedded  in  the  sand.  On  the 
third  day  the  cumol  is  removed  and  the  dry-heat  process  is 
repeated  exactly  as  on  the  first  day.  On  the  fourth  day  the 
coils  are  immersed  in  alcohol  and  heated  in  the  steam  sterilizer 
under  25  pounds  pressure  for  one  hour.  On  the  fifth  day  the 
fourth-day  process  is  again  repeated.  This  is  essentially  the 
method  employed  by  the  manufacturers,  except  that  the  coils 
are  placed  in  glass  tubes  at  the  beginning  of  the  process  and 
these  are  filled  with  alcohol  and  sealed  in  the  blow-pipe  flame 
at  the  end  of  the  third  day's  sterilization. 

Third  Method. — Dry  heat  sterilization  in  alboline  (method  of 
Dr.  Willard  Bartlett).  The  preliminary  preparation  and  the 
first  day's  sterilization  are  exactly  the  same  as  described  under 
the  first  method.  The  coils  are  then  placed  in  an  asbestos-lined 
kettle  containing  liquid  alboline.  They  are  left  immersed  in  the 
alboline  in  a  warm  place  for  twenty-four  hours,  or  until  the 
strands  become  semitranslucent.  The  second  and  in  this  case 
final  sterilization  is  done  by  heating  over  a  sand  bath  as  described 
under  the  second  method.  Heat  is  applied  gradually  until  at 


270  THE  OPERATION 

the  end  of  an  hour  and  a  half  the  temperature  of  the  alboline 
has  reached  320°  F.  At  this  temperature  it  is  maintained  for 
one  hour.  This  completes  the  process.  The  gut  is  stored  in  a 
one  per  cent,  iodine  solution  in  alcohol.  This  should  be  contained 
in  a  large-mouthed  glass  jar  with  ground  glass  stopper.  The  coils 
are  transferred  to  the  jar  from  the  hot  alboline  with  a  sterile 
instrument.  The  jar  itself  should  be  provided  with  a  closely 
fitting  cover  of  metal  or  heavy  Manila  paper  (to  protect  the 
lip  from  dust),  and  the  whole  sterilized  by  dry  heat  at  150°  F. 
for  one  hour  before  it  is  filled  with  the  solution.  The  coils  should 
be  drained  of  alboline  and  rinsed  in  the  same  solution  before 
being  placed  in  the  jar.  The  lip  of  the  jar  should  be  wiped  with 
a  sterile  bichloride  sponge  whenever  the  stopper  is  to  be  taken 
out  for  the  purpose  of  removing  with  a  sterile  instrument  the 
coils  of  catgut  as  they  are  required. 

Fourth  Method. — Iodine  sterilization  (method  of  Claudius). 
The  coils  after  the  preliminary  preparation  are  simply  immersed 
in  a  1  per  cent,  solution  of  iodine  in  alcohol.  They  remain  per- 
manently in  this  solution,  and  must  have  been  subjected  to  it 
for  two  weeks  before  they  are  used.  This  method  is  in  use  in 
many  institutions.  It  is  open  to  suspicion  from  the  theoretical 
stand-point,  but  a  very  extensive  experience  in  practice  seems  to 
show  that  it  is  reliable  for  smaller  sizes  of  catgut  at  least;  for 
the  larger  sizes,  however,  it  is  probably  unsafe. 

Kangaroo  tendon  may  be  sterilized  in  the  same  manner  as 
catgut,  but  it  does  not  stand  the  high  temperatures  so  well. 

4.  Drains. — These  are  placed  in  infected  wounds  to  provide 
for  the  escape  of  pus,  and  sometimes  in  very  extensive  clean 
wounds  to  prevent  accumulation  of  blood  or  serum  in  the  wound. 
In  this  latter  case  the  drain  is  always  removed  at  the  first  dressing. 
In  infected  wounds  the  drains  remain  usually  for  a  longer  time. 
The  materials  used  for  drains  are  glass  tubing,  rubber  tubing, 
strips  of  gauze  and  gutta-percha  tissue,  or  the  so-called  rubber 
dam  used  in  dentistry.  The  manufacturers  supply  glass  drains 
of  suitable  sizes  and  shapes  and  of  properly  annealed  glass  so 
that  they  may  not  be  broken  easily.  Rubber  tube  drains  are 
made  as  wanted  from  tubing  of  suitable  size,  usually  from  }^  to 
%  inch  in  diameter,  and  four  to  six  inches  long.  Side  holes 
are  usually  cut  in  the  tube,  and  it  is  sometimes  split  lengthwise 
either  in  a  straight  line  or  spirally.  A  "dressed  tube"  drain  is 
made  of  rubber  tubing  wrapped  first  with  several  layers  of  gauze 


OPERATING  MATERIAL  271 

and  then  with  gutta-percha  tissue.  A  "cigarette"  drain  or 
''wick"  is  made  from  a  strip  of  gauze  wrapped  with  gutta-percha 
tissue  or  rubber  dam.  One  end  of  the  strip,  free  from  ravellings, 
should  extend  beyond  the  gutta-percha  wrapping  for  about  half 
an  inch.  Another  form  is  made  from  a  square  of  gutta-percha 
tissue  placed  between  two  single  thicknesses  of  gauze  and  rolled. 
A  folded  strip  of  gutta-percha  tissue  or  several  strands  of  some 
ligature  material  twisted  together  will  sometimes  be  called  for 
when  a  very  small  drain  is  required.  Glass  and  rubber  are 
sterilized  by  boiling:  gutta-percha  tissue  melts  at  a  low  tempera- 
ture and  must  be  sterilized  by  storing  in  1-1000  bichloride  solu- 
tion. These  drains  are  usually  made  tip  as  needed  at  the  operating 
table.  For  drainage  of  the  gall-bladder  a  rubber  tube  of  JjJ-inch 
lumen,  about  14  to  18  inches  long,  will  be  needed.  The  tube  is 
"dressed"  at  one 'end  with  selvage  gauze  and  gutta-percha 
tissue,  and  will  bo  fitted  over  a  glass  connection  tube  at  the  other 
end  with  which  to  attach  it  to  a  longer  tube  at  the  bedside. 

5.  Medicated  Gauzes. — Gauzes  impregnated  with  iodoform 
and  other  chemical  substances  are  still  in  use  to  some  extent. 
They  are  a  survival  of  the  antiseptic  as  distinguished  from  the 
present  aseptic  era  in  surgery,  and  their  use  is  becoming  more 
and  more  limited.     They  arc  still  used  in  drains  to  some  extent . 
and  to  pack  in  septic  wounds.     The  formula;  for  these  gauzes 
are  given  elsewhere. 

6.  Other  materials  are  occasionally  buried  in  a  wound  to 
accomplish  various  purposes.     Horseley's  bone  wax  is  used  to 
check  hemorrhage  in  bone,  steel  plates  and  screws  to  fix  fractures, 
the  Murphy  button  in  making  an  intestinal  anastomosis,  and  so 
on.    Most  of  these  belong  rather  to  the  instrumental  outfit  than 
to  the  classes  of  operative  material  to  be  prepared  by  the  nurse 
which  are  under  consideration  in  this  chapter. 

IV.  WOUND  DRESSINGS 

1.  Gauze. — The  forms  and  sizes  in  which  gauze  dressings  are 
put  up  vary  considerably  in  different  institutions.  It  is  not 
claimed  that  those. presented  here  are  superior  to  others.  They 
may  serve  as  types  of  the  various  .forms  of  dressings  in  use. 

(1)  Fluffs  are  made,  of  threerquarters  of  a  yard  of  gauze  cut 
from  the  bolt,  opened  out  singly,  the  raw  edges  turned  in  and 
crushed  in  the  hand.  In  use.  they  are.  shaken  out  and  arranged 


272  THE  OPERATION 

in  loose  masses  over  and  about  the  wound.    This  makes  a  soft, 
comfortable  and  very  absorbent  dressing. 

(2)  Pads  are  made  of  pieces  of  gauze  cut  in  various  lengths 
from  the  full  width  of  the  bolt  (one  yard)  and  folded  into  square 
or  oblong  shape,  with  raw  edges  covered  in,  making  pads  of 
various  sizes  and  from  four  to  twelve  layers  of  gauze  in  thickness. 
Common  sizes,  for  example,  will  be  4  by  4,  4  by  9,  and  8  by  12 
inches. 

(3)  Compresses  are  made  of  thick  layers  of  absorbent  cotton 
cut  into  square  or  oblong  shape  in  convenient  sizes  and  covered 
on  both  sides  with  a  double  thickness  of  gauze.     The  cotton  is 
elastic  and  enables  a  firm  and  evenly  distributed  pressure  to  be 
made  in  the  neighborhood  of  the  wound  by  compression  with  the 
roller  bandage. 

(4)  Gauze  rolls  are  made  from  six  yards  of  gauze,  already 
doubled  once  lengthwise  on  the  bolt,  folded  end  to  end,  and 
then  folded  in  three  parts  lengthwise  and  rolled.    This  makes  a 
roll  of  gauze  of  twelve  thicknesses,  six  inches  wide  and  three 
yards  long.     They  are  put  on  like  a  roller  bandage,  loosely,  in 
dressing  wounds  of  the  neck,  breast,  shoulder  and  arm,  as  a 
spica  after  hernia  operations,  and  after  operations  on  the  lower 
extremity. 

(5)  Tampons  are  used  to  pack  cavities,  and  are  made  either 
of  pledgets  of  cotton  or  wool  tied  on  a  string,  or  more  usually 
of  narrow  strips  of  plain  or  medicated  folded  gauze. 

(6)  Uterine  gauze  tape  or  packing  is  made  from  a  strip  of 
gauze  2  inches  wide  and  5  yards  long.    A  somewhat  closer  weave 
of  gauze  than  that  usually  employed  for  dressing  material  is  to 
be  preferred.     The  gauze  is  folded  from  each  side  to  the  centre 
line,  and  folded  again  on  the  centre  line,  making  a  tape-like  strip 
J/£  inch  wide.    Each  strip  should  be  packed  in  a  glass  tube  (large 
test  tube)  which  is  plugged  with  cotton,  and  the  cotton  plug  and 
lip  of  tube  covered  with  a  few  turns  of  gauze  bandage  fastened 
with  adhesive  plaster,  and  sterilized  under  steam  pressure. 

(7)  Vaginal  packing  is  made  from  a  strip  of  gauze  half  the 
width  of  the  bolt  (18  inches)  and  5  yards  long.     The  selvage 
and  raw  edge  are  folded  to  centre  line,  then  folded  to  centre  line 
again  and  doubled  on  centre  line.     This  gives  a  strip  of  eight 
thicknesses  of  gauze  2%  inches  wide.   Another  method  is  to  turn 
in  the  raw  edge,  roll  the  gauze  toward  the  selvage  edge,  and  pull 
through  the  hands  in  the  form  of  a  rope.    This  is  coiled  and  steril- 


OPERATING  MATERIAL  273 

ized  in  a  muslin  wrapper  or  in  a  large  glass  tube,  plugged  as  in 
the  case  of  the  uterine  gauze. 

(8)  Rectal  Plug.    A  large  dressed  tube  wound  with  gauze  to 
the  thickness  of  one  inch  and  covered  with  vaseline  or  protective 
is  used  in  the  rectum,  after  hemorrhoid  operations. 

(9)  Silver  foil  as  a  dressing  material  for  wounds  is  used  to 
cover  the  lips  of  the  wound  before  the  gauze  dressings  are  applied. 
It  comes  laid  between  sheets  of  thin  tissue  paper  sewed  together 
at  one  edge  in  the  form  of  a  book.    The  sewed  edge  is  trimmed  off 
with  scissors  and  the  package  is  then  placed  between  two  pieces 
of  thick  binding  board,  wrapped  with  muslin  and  sterilized  in 
the  steam  sterilizer. 

2.  Gutta=percha  tissue,  designated  usually  as  "  protective," 
is  made  from  the  dried  sap  of  a  tropical  tree.    Its  principal  com- 
mercial use  is  as  an  insulating  material,  particularly  in  the  manu- 
facture of  ocean  cables.     In  surgery  it  is  employed  in  the  form 
of  thin  sheets  as  a  protective  covering  for  wounds,  and  in  making 
cigarette  drains.     Immersion  in  bichloride  solution  is  the  only 
practical  means  of  sterilizing  it. 

3.  Crepe  lisse,  or  fine  silk  bolting  cloth,  is  sometimes  used, 
fixed  to  the  skin  with  collodion,  to  draw  together  the  lips  of 
small  wounds.    Fine  batiste,  gauze  or  silk,  dipped  in  celloidin, 
may  be  used  to  protect  wider  areas  of  the  skin  in  the  neighbor- 
hood of  a  wound.    A  coarse  linen  net  impregnated  with  celloidin 
is  recommended  for  fixing  and  holding  skin  grafts  in  place. 
These  materials  are  sterilized  and  are  cut  to  suitable  sizes  for 
each  individual  case  at  the  time  they  are  used. 

V.  MATERIALS  FOR  THE   FIXATION  OF  WOUND   DRESSINGS 

Strips  of  adhesive  plaster  two  or  three  inches  wide  are  uni- 
versally employed  to  fix  dressings  in  place  over  abdominal 
wounds  particularly,  but  also  in  many  other  situations.  The 
plaster  is  not  sterilized  and  may  or  may  not  be  covered  with  a 
binder  or  roller. 

Roller  bandages  are  made  from  one  to  six  inches  in  width 
and  ten  yards  long.  The  material  is  unbleached  muslin  or  gauze 
of  a  tighter  weave  than  that  used  for  dressings,  usually  thirty 
to  forty  threads  to  the  inch.  Four  inches  is  the  widest  muslin 
bandage  that  can  be  advantageously  used.  It  is  a  convenience 
and  an  economy  to  use  wider  gauze  bandages  (six  inches)  in 
18 


274  THE  OPERATION 

fixing  large  dressings  in  the  operating  room.  The  bandages  are 
not  usually  sterilized  except  for  special  cases.  The  supply  of 
roller  bandages  in  the  several  sizes  should  be  abundant.  The 
method  of  preparing  them  is  described  in  another  chapter. 

The  abdominal  binder  is  a  broad  belt,  made  to  encircle  the 
abdomen,  overlapping  in  front  and  to  be  fastened  with  safety 
pins.  It  is  made  of  a  single  or  double  thickness  of  unbleached 
muslin,  and  in  a  number  of  sizes.  Standard  sizes  are  14  inches 
by  1  yard,  16  by  40  inches,  16  by  46  inches. 

The  scultetus  or  many-tailed  bandage  is  an  abdominal  binder 
of  which  each  end  is  divided  into  six  or  eight  tails,  leaving  a 
solid  piece  at  the  back  about  ten  or  twelve  inches  wide. 

A  better  form  is  made  of  four  strips,  each  seven  inches  wide, 
the  top  three  46  inches  and  the  lowest  50  inches  long.  These 
are  laid  together  so  that  each  strip  overlaps  the  one  above  it  by 
one-half  its  width,  and  sewed  securely  throughout  the  middle 
twelve  inches,  thus  leaving  four  tails  at  each  end.  The  advantage 
of  this  binder  is  that  it  can  be  made  to  fit  very  smoothly  over  the' 
abdomen.  A  sufficient  number  of  safety  pins  must  be  used  to 
secure  all  the  loose  ends. 

The  T-bandage  is  used  to  fix  perineal,  vulvar  or  rectal  dress- 
ings in  place.  It  consists  of  a  four-inch  belt  with  one  or  two 
strips  three  inches  wide  sewed  to  its  middle  at  right  angles  to 
it.  This  bandage  can  be  readily  improvised  from  strips  of  suitable 
length  taken  from  a  four-inch  muslin  roller. 

VI.  METHODS  OF  ASSEMBLING  AND  STERILIZING  OPERATING 

MATERIAL 

Sponges  and,  particularly,  abdominal  packs  must  be  put  up 
for  sterilization  in  packages  each  containing  a  definite  number, 
so  that  strict  account  of  them  can  be  kept,  in  order  to  guard 
against  the  possibility  of  one  of  these  articles  being  left  in  the 
abdominal  cavity.  The  covers  in  which  the  goods  are  wrapped 
are  made  of  heavy  unbleached  muslin  doubled  and  stitched 
together.  The  towels  are  put  up  in  packs  one  dozen  or  one-half 
dozen  in  each.  Each  sheet  and  gown  is  placed  in  a  separate 
package.  Single  packages  of  gauze  dressings  of  every  kind  should 
be  kept  on  hand,  put  up,  for  example,  as  follows:  fluffs  and  pads, 
one  dozen  in  each  package;  gauze  rolls,  one  or  two  in  each  pack- 
age; large  crushed  sponges,  one  dozen  in  each  package;  stick 
sponges  and  folded  sponges,  two  dozen  in  each  package;  tape 


OPERATING  MATERIAL  275 

packers,  one-half  dozen  in  each  package.  These  are  only  illus- 
trative, the  practice  varying  in  every  point  in  different  operating 
rooms.  The  essential  thing  is  to  have  an  established  and  definite 
system.  It  is  well  to  have  a  plan  whereby  the  responsibility  can 
be  fixed  for  errors  in  counting.  For  example,  sponges  and  packers 
may  be  counted  separately  by  two  nurses  whose  names,  on  a 
slip  of  paper,  are  included  in  each  package. 

The  Operating  Unit  Package. — Large  packages  containing 
everything  necessary  for  a  particular  operation  are  prepared  and 
put  up  either  in  large  muslin  wrappers  or  in  metal  drums  manu- 
factured for  the  purpose.  These  drums  are  12  inches  in  diameter 
and  9  to  12  inches  high.  The  drum  is  pierced  with  a  row  of  holes 
around  the  circumference  at  the  top  and  bottom.  A  sliding 
band  with  corresponding  holes  enables  these  to  be  opened  or 
closed  at  will.  The  openings  are  for  the  purpose  of  enabling  the 
steam  to  penetrate  to  the  contents  of  the  drum,  and  are  closed 
when  the  drum  is  taken  from  the  sterilizer.  When  ready  for 
use  the  drum  is  placed  on  a  stand  so  arranged  that  the  cover 
may  be  lifted  by  means  of  a  foot  lever  (Fig.  88).  For  example, 
the  laparotomy  package  or  drum  may  contain  18  towels,  1  lapa- 
rotomy  sheet,  1  small  sheet,  2  large,  4  medium  and  2  small 
packers^  2  packages  of  sponges,  2  of  fluffs,  2  of  large  pads,  a  small 
wad  of  cotton  for  application  of  iodine,  etc.,  4  gowns,  1  binder. 
There  will,  of  course,  be  more  or  less  variation  in  the  make-up 
of  these  packages  in  different  operating  rooms. 

Sutures  and  Ligatures. — The  preparation  of  these  for  ordinary 
use  has  already  been  described.  Special  methods  of  assembling 
the  sutures  used  in  operating  upon  the  intestines  and  upon 
arteries  and  veins  are  usually  employed. 

For  intestinal  sutures  fine  silk  or  linen  is  cut  into  fourteen- 
inch  lengths  and  threaded  on  No.  7  milliner's  needles.  These 
are  then  basted,  in  parallel  lines  about  half  an  inch  apart,  into 
strips  of  muslin  or  small  towels,  one-half  dozen  in  each.  The 
strips  are  then  folded,  enclosed  in  muslin  wrappers,  and  sterilized 
in  the  steam  sterilizer.  The  thread  must  be  fastened,  either  by 
tying  into  the  eye  of  the  needle  with  a  single  knot  about  two 
inches  from  one  end,  or  better  by  transfixing  the  thread  with 
the  point  of  the  needle,  two  inches  from  the  end,  and  drawing 
the  perforated  thread  down  to  the  eye.  This  fastens  the  thread 
without  adding  the  bulk  of  a  knot.  These  threaded  needles,  as 
they  are  called,  are  also  much  used  in  ordinary  work,  including 


276 


THE  OPERATION 


the  suturing  of  the  skin.     Small,  curved,  round  needles  may  be 
used  in  place  of  the  straight  needles  by  those  who  prefer  them. 

Operations  involving  the  suturing  of  large  arteries  and  veins, 
so  as  to  preserve  the  continuity  of  the  circulation,  present  a 
problem  in  technic  of  very  great  difficulty  on  account  of  the 
tendency  of  the  blood  to  clot  wherever  the  walls  of  the  vessels 
have  been  injured,  and  the  danger  of  leakage  due  to  the  powerful 

pressure   of   the    arterial    blood   t^-  _ 

stream.     The  methods  for  such   F  ^fMHjffe^^ 

suturing  have  been  developed 
in  recent  years  to  a  high  degree 
of  perfection,  but  their  use  re- 
quires great  skill  on  the  part 
of  the  surgeon,  attainable  only 
by  careful  practice,  which  is  best 
secured  by  experimental  work  on 
the  lower  animals. 

Straight  needles  threaded  with 
silk  are  used,  both  of  a  degree  of 
fineness  not  obtainable  through 
ordinary  commercial  channels, 
and  they  must  be  prepared  in 


Fio.  90. — Needle  and  thread 
for  suture  mounted  and  ready  for 
sterilization  (Bernheim). 


FIG.  91. — Flask  containing  liquid  vase- 
line and  four  mounted  needles  for  arterial 
suture.  Sterilized  and  kept  as  stock. 


a  special  manner.  The  Kirby  needles  (made  for  lace  makers) 
Nos.  16,  17  or  18,  with  Alsace  thread  No.  500,  were  originally 
recommended  by  Carrel  for  this  purpose.  No.  00000  (five  naught) 
silk,  furnished  by  Belding  Bros.  &  Co.  of  New  York,  and  No.  12 
ground  down  needles,  made  by  H.  Milward  and  Sons,  are  recom- 
mended in  a  recent  work  by  Bernheim.  For  the  preparation  of 
arterial  sutures  the  technic  given  by  Bernheim  may  be  accepted 


OPERATING  MATERIAL  277 

as  standard.  The  special  fine  silk  is  cut  into  twelve-inch  lengths, 
threaded  into  the  tiny  Kirby  or  Milward  needles  and  the  ends 
drawn  even.  The  thread  is  not  tied  or  fixed  in  the  eye  of  the 
needle.  The  needle  is  pinned  into  a  small  piece  of  writing  paper 
about  1/2  inch  by  1  inch  in  size  (Fig.  90),  and  the  doubled  thread 
wound  about  the  needle  in  a  figure-of-eight,  the  ends  being  caught 
in  a  slit  in  one  corner  of  the  paper.  Four  needles  so  threaded  are 
placed  in  a  small  flask  containing  two  ounces  of  liquid  vaseline 
(Fig.  91),  which  is  plugged  with  cotton  and  capped  with  gauze, and 
sterilized  in  the  ordinary  way  in  the  steam  sterilizer.  At  the  opera- 
tion the  flask  is  emptied  into  a  dry  sterile  medicine  glass  placed  on 
the  operating  table.  The  sutures  are  not  to  be  touched  by  the 
instrument  nurse,  but  handled  only  by  the  operator.  Two  or 
more  sterile  medicine  droppers,  with  fine  points,  are  provided 
to  be  used  for  washing  out,  with  normal  salt  solution  and  liquid 
vaseline,  the  blood-vessels  where  the  sutures  are  being  applied. 


CHAPTER  XXI 

SURGICAL  INSTRUMENTS 

THE  nurse  who  enters,  for  the  first  time,  upon  operating- 
room  duty  is  likely  to  experience  a  sense  of  strangeness  and  con- 
fusion far  surpassing  any  that  she  may  have  known  in  other 
branches  of  her  work.  Not  only  is  the  work  itself  unfamiliar 
to  her,  but  the  very  utensils  and  instruments  are  frequently 
unknown  to  her  even  by  name,  and  much  less  so  by  use.  The 
effort  of  this  chapter  will  be  to  familiarize  the  nurse  not  only 
with  the  names  and  appearances  of  the  more  common  instruments 
but  also  with  the  grouping  in  which  they  occur  in  different  opera- 
tions and  the  order  in  which  they  may  be  demanded  during  the 
different  successive  steps  of  these  operations.  It  is  hoped  that 
this  discussion  will  render  easier  the  recognition  and  selection 
of  the  different  instruments  when  called  for  and,  also,  the  proper 
arrangement  and  prompt  delivery  of  instruments  during  opera- 
tions. 

It  may  be  stated,  in  general  terms,  that  every  operation  (not 
solely  manipulative  in  character)  calls  for  the  use  of  five  general 
classes  of  instruments:  cutting,  clamping,  holding,  exposing,  and 
sewing.  Each  of  these  classes  must,  necessarily,  include  many 
different  varieties  to  suit  the  particular  demands  of  the  region 
and  nature  of  the  particular  operation.  An  effort  will  be  made 
to  give  a  general  description  of  the  different  instruments  occurring 
in  each  class,  the  more  definite  and  accurate  description  being 
left  to  the  illustrations. 

1.  Cutting  Instruments. — These  are,  broadly  speaking,  knives 
and  scissors  (Fig.  92)  for  work  in  the  soft  tissues  and  drills, 
trephines  (Fig.  93),  curettes  (Fig.  94),  cutting  forceps  (Fig.  95), 
chisels  (Fig.  96)  and  saws  (Fig.  97)  for  work  in  bony  tissue.  The 
knives  may  again  be  divided  into  three  main  classes:  scalpels, 
bistouries  and  amputating  knives.  The  scalpel  is  a  small,  straight 
knife,  with  the  blade  and  handle  generally  made  of  one  piece 
of  metal,  and  the  blade  flat,  convex  towards  the  edge  and  consti- 
tuting from  one-third  to  one-fifth  of  the  total  length  of  the  knife. 
The  bistoury  is  very  similar,  except  for  a  lighter,  narrower  blade, 
which  may  vary  greatly  in  shape  with  the  purpose  for  which 
278 


SURGICAL  INSTRUMENTS  279 

destined.  The  amputating  knife  is  a  much  larger  and  more 
formidable  looking  instrument.  The  blade  is  apt  to  be  nine 
inches,  or  even  more,  in  length,  possibly  double-edged,  and  the 
handle  only  sufficiently  large  to  furnish  an  efficient  grip  to  the 
hand.  It  is  scarcely  necessary,  or  indeed  possible,  to  describe 
the  scissors.  The  general  character  is  known  to  all  and  the 
different  varieties  are  legion.  It  is  sufficient  to  say  that  surgical 


FIG.  92. — Cutting  instruments:  knives  and  scissors.  (1)  Scalpels;  (2)  tenotomy  knives; 
(3)  bistouries,  straight  and  curved,  sharp  and  blunt ;  (4)  amputating  knives — Liston's,  Catling 
(double  edge);  (5)  scissors,  sharp  and  dull  points;  (6)  Littauer's  suture  scissors;  (7)  Lister's 
bandage  scissors;  (8)  Emmet's  uterine  scissors;  (9)  Mayo  scissors;  (10)  "American"  um- 
bilical scissors. 

scissors  vary  in  type  from  the  very  small  (adapted  to  the  most 
delicate  work)  to  the  heavy,  scissors-like,  bone-cutting  forceps 
that  are  capable  of  cutting  through  a  rib. 

The  drills  used  in  bone-work  vary  in  size  from  one  small 
enough  to  make  a  hole  for  the  passage  of  moderately  fine  silver 
wire  to  the  heavy,  burr-tipped  drill  now  largely  used  to  supplant 
the  old  circular  saw  (or  trephine)  in  cranial  operations.  The 
saws,  also,  vary  largely,  both  as  to  size  and  shape.  The  trephine 


280 


THE  OPERATION 


2    3.2 


SURGICAL  INSTRUMENTS 


281 


I 


282 


THE  OPERATION 


FIG.  97. — Cutting  instruments:  bone  saws.  (1,  2)  Metacarpal  saws;  (3)  metacarpal  saw 
(lifting  back) ;  (4)  Satterlee's  saw;  (5)  Hey's  skull  saw;  (6)  Gigli's  wire  saw.  (For  bow  type 
of  saw  see  Fig.  129.) 


(mentioned  above)  is  nothing  more  than  a  ring  of  metal  with  a 
saw  edge,  used  for  removing  a  circular  button  of  bone  from  the 
skull  in  intracranial  operations.  The  Gigli  saw  is  a  pliable  wire, 
roughened  so  as  to  more  resemble  a  file  than  a  saw  and  used  for 


SURGICAL  INSTRUMENTS  283 

work  where  the  instrument  can  be  passed  around  the  bone  to 
be  cut  and  the  work  done  through  a  small  aperture  with  minimum 
danger  to  the  soft  tissues.  Bone-cutting  forceps  are  generally 
fairly  heavy  instruments,  built  on  the  scissors  principle  and  with 
strong  cutting  edges,  which  may  be  either  straight  or  curved  to 
resemble  a  scoop.  A  curette  is  merely  a  metal  scoop  with  a 
handle  sufficiently  substantial  to  furnish  a  good  grip.  It  might 
be  mentioned  that  the  use  of  the  curettes  is  not  confined  to  bony 
tissue,  one  of  the  most  marked  exceptions  being  the  long-handled 
curette  used  for  scraping  the  uterus. 

2.  Clamping  Instruments  (Figs.  98-101). — These  instruments 
may  be  described,  in  general  terms,  as  any  planned  for  the 
temporary  control  of  the  escape  of  fluid  from  its  containing  part. 
The  reason  for  the  very  broad  limits  of  this  definition  will,  per- 
haps, be  better  appreciated  when  the  extremely  broad  applica- 
tion of  this  type  of  instrument  is  understood.     The  principle  of 
construction  is  very  nearly  related  to  that  of  the  scissors  so  far 
as  appearances  go.    The  difference  lies  in  the  absence  of  a  cutting 
edge;  the  close  approximation,  under  pressure,  of  the  flattened 
blades,  when  closed;  and  a  catch  locking  device  near  the  ends  of 
the  handles.    As  would  be  supposed,  the  most  common  type  and 
use  of  this  instrument  is  for  the  temporary  prevention  or  control 
of  hemorrhage.    The  different  instruments  vary  in  size  from  com- 
paratively small  ones  designed  for  the  seizure  and  control  of  a 
single  bleeding  vessel  to  the  quite  heavy  ones,  expected  to  grasp 
a  large  section  of  tissue  (possibly  containing  several  large  vessels) 
and  prevent  the  possibility  of  bleeding.     Any  particular  instru- 
ment of  this  type  may,  of  course,  be  applied  to  a  small  opening 
in  a  tumor  containing  fluid  or  even  in  the  bladder,  for  the  purpose 
of  temporarily  preventing  the  escape  of  septic  material  into  the 
abdominal  cavity.    Another  large  class  of  clamping  instruments 
is  designed  for  operations  upon  the  digestive  tract.    The  blades 
(Fig.  101)  of  these  are  longer,  more  springy  and  less  rigid  and  gen- 
erally covered  with  rubber  tubing  to  prevent  permanent  injury 
to  the  delicate  gut.     A  third  group  is  designed  for  temporary 
control  of  the  circulation  in  operations  upon  the  vascular  system. 

3.  Holding   Instruments  (Figs.   102-103). — It  must  be  ac- 
knowledged that  this  class  of  instruments  is  scarcely  a  distinct 
entity  in  itself,  as  instruments  designed  for  other  purposes  (par- 
ticularly those  of  the  clamping  type)  are  frequently  made  use  of 
in  this  connection.     There  is,  however,  one  broad  class  here 


284  THE  OPERATION 

FIG.  98.  FIG.  99. 


FIG.  100.  Fia.  101. 

FIG.  98. — Clamping  instruments:  haemostatic  clamps.  (1)  Kocher's;  (2)  Halsted's  mos- 
quito: (3)  Taite's;  (4)  Pean's;  (5)  Halsted's;  (6)  Kocher's;  (7)  Kelly's;  (8)  Ochsner's. 

FIG.  99. — Clamping  instruments.  (1)  Von  Blunk's;  (2,  3, 4)  Pean's;  (5)  Kelsey's  hemor- 
rhoidal  clamp. 

FIG.  100. — Clamping  instruments.  (1)  Kelly-Murphy;  (2)  Pean's  "T"  clamp;  (3) 
straight  sponge  stick;  (4)  Foerster's  straight  clamp;  (5)  Foerster's  curved  clamp. 

FIG.  101. — Clamping  instruments.  (1,2)  Intestinal  clamps;  (3,4)  stomach  clamps  (1, 
Wright's;  2,  Kocher's;  3-4,  Mayo-Robson). 

included  and,  in  addition  to  that,  numerous  auxiliaries  that  have 
this  object.    The  prominent  general  class  of  holding  instruments 


FIG.  102. 


FIG.  103. 


FIG.  102. — Holding  instruments. 


(1)  Halsted's  mouse-toothed  forceps;  (2,  3)  dressing 

forceps;  (4)  tongue  holding  forceps  (Houze's);  (5)  bone  clamps  (Holdcns);  (6)  Ferguson's 
lion-jaw  hone-holding  forceps;  (7)  sequestrum  forceps  (Van  Huron's);  (8)  Doyen's  tissue- 
holding  forceps;  (9)  tenaculum. 

FIG.  103.— Holding  instruments.  (1)  Richter's  volspllum  forceps;  (2)  Skene's  volsel- 
lum  forceps  (also  oafled  double  tenneiiluni  or  Mullet  [creeps);  (3)  Ernmot's;  (4)  Foer- 
ster's  sponge  or  dressing  forceps;  (5)  Richter's;  (6)  Colliu'a  uterus  holding  forceps. 


286 


THE  OPERATION 


Fio.  104. — Exposing  instruments:  retractors.  (1)  Sharp  hook  retractors  (Simon's, 
Volkmann'a);  (2)  Halsted's;  (3)  Kelly's;  (4)  Richardson's;  (5)  Langenbeck's;  (6)  Freer's 
retractors. 

is  that  of  the  dissecting  forceps  (Fig.  102,  Nos.  1,  2  and  3). 
These  are  otherwise  variously  described  as  tissue  forceps,  or 
thumb  forceps.  The  names  "dissecting,"  or  "tissue,"  forceps  are 
somewhat  descriptive  of  their  use.  They  are  really  the  left  hand 


SURGICAL  INSTRUMENTS 


287 


of  the  operator.  They  closely  resemble  large  tweezers  in  appear- 
ance and,  with  them,  the  operator  grasps  and  steadies  the  tissues 
immediately  under  his  attention,  using  them  for  the  thousand 
and  one  purposes  for  which  the  fingers  of  the  left  hand  would 
ordinarily  be  called  into  play  were  they  not  too  slippery  and  cum- 
bersome for  delicate  work.  These  instruments  are  generally  de- 
scribed as  smooth  or  mouse-tooth  (or  even  rat-tooth,  or  merely 
tooth)  forceps,  according  to  whether  the  grasping  tip  is  or  is  not 
armed  with  teeth  to  make  a  more  secure  hold  possible.  They 


Fio.  105. 


FIG. 106. 


Fia.  105. — Exposing  instruments:  retractors.     (1)  Kelly's;  (2)  Langenbeck's;  (.3)  Doyen's; 

(4)   Jackson's;    (5)   Young's  vesical   (bladder)   retractor. 
Fia.  106. — Exposing  instruments:  retractors.     (1,  2,  3)  Y'oung's;  (4)  Simpson-Mayo. 

are  made  comparatively  short  for  work  on  the  surface  or  in  easily 
accessible  localities  and  twelve  inches  or  more  in  length  for  work 
in  less  accessible  cavities.  In  addition  to  this  class,  brief  mention 
may  be  made  of  such  instruments  as  tongue-holding  forceps  (Fig. 
102,  No.  4),  for  seizing  and  making  traction  on  the  tongue;  and 
the  numerous  forceps  of  the  clamp  type  designed  for  the  proper 
seizure  and  exposure  of  the  uterus  in  gynaecological  operations. 
The  latter  instruments  are  known  as  single  or  double  tenaculum 
forceps  (Fig.  103,  No.  2),  volsellum  forceps  (Fig.  103,  Nos.  1 


288 


THE  OPERATION 


SURGICAL  INSTRUMENTS 


289 


and  5)  and  uterine  elevating  forceps,  according  to  whether  the 
grasp  is  rendered  secure  by  a  single,  unopposed  fine  point;  two 
opposed  fine  points;  several  opposed  heavy  teeth;  or  a  somewhat 
encircling  grasp  independent  of  teeth  (Fig.  103,  No.  6) 

4.  Exposing  Instruments  (Figs.  104  to  108). — Exposing  in- 
struments are,  as  a  rule,  broad-bladed,  blunt  hooks,  known  as 
retractors,  of  varying  sizes  that  are  used  to  draw  back  the  edges 
of  the  wound  in  order  to  give  a  better  exposure  of  the  deep  struc- 
tures. Beyond  the  limits  of  this  definition  come  the  atypical 
retracting  instruments — generally  called  specula  (Figs.  107  and 


10 


FIG.  109.— Surgical  needles:  (1)  Glover's  needle;  (2)  triangular  point;  (3)  Halsted-Hage- 
dorn;  (4)  surgeon's  half  curved;  (5)  Emmet's  half  curved;  (6,7)  intestinal  needles;  (8) 
surgeon's  full  curved;  (9)  Halsted-Hagedorn,  full  curved;  (11)  Kelly's;  (12)  Lister's. 

108).  These  serve  the  same  purpose,  but  in  a  somewhat  differ- 
ent way.  They  are  used  in  order  to  expand  closely  approximated 
canals  communicating  between  the  outer  air  and  the  body 
cavities.  Thus,  we  have  nasal,  aural,  vesical,  vaginal  and  rectal 
specula.  They  may  accomplish  their  purpose  by  the  simple 
introduction  of  a  tube  that  gives  a  free  field  of  vision  through 
its  lumen  (tubular  specula),  or  by  the  separation  of  blades  that 
force  back  the  adjacent  tissues  (bivalve  or  tri valve  specula). 

5.  Sewing   Instruments. — The  sewing  instruments  may  be 
divided  into  needles  (Fig.  109)  and  needle  holders  (Fig.  110). 
19 


290  THE  OPERATION 

While  it  is  not  necessary  to  use  a  needle-holder  in  surface  sewing, 
it  is  quite  common  for  operators  who  have  become  used  to  the 
holder  in  deep  work,  where  it  was  necessary,  to  also  use  it  on  the 
surface  where  this  is  not  the  case.  The  needle-holder  is  generally 
some  modification  of  an  instrument  of  the  clamping  type,  which 
holds  the  needle  firmly  and  permits  untrammelled  work  in  the 
less  accessible  localities.  The  needles  used  for  surgical  sewing 
are,  if  anything,  more  varied  as  to  construction  and  application 
than  the  other  surgical  accessories,  which  seem  limited  only  by 
the  individual  preference  of  the  operators  using  them.  Needles 
may,  however,  be  generally  subdivided,  according  to  shape,  into 
straight  and  curved,  and,  according  to  section,  into  round  and 
cutting.  The  use  of  the  straight  needle  is  almost  necessarily 
confined  to  readily  accessible  parts,  as  in  other  regions  the  re- 
covery of  the  point  after  passage  might  be  a  matter  of  considerable 
difficulty.  These  needles  may,  in  turn,  be  either  round  or  cutting. 
The  round,  straight  needle  does  not  materially,  if  at  all,  differ 
from  the  ordinary  household  needle.  It  is  best  adapted  (as  are 
all  of  the  round  needles)  for  work  in  delicate,  or  friable  tissue, 
where  the  danger  of  the  stitch  cutting  out  is  ever  present  and  must 
be  reduced  to  a  minimum.  It  may  be  said  that  the  generally 
accepted  use  of  the  fine,  round  needle  (whether  straight  or  curved) 
is  in  visceral  work  where  serous  surfaces  are  to  be  united.  This 
includes  operations  upon  the  intestines,  stomach  and  urinary 
bladder.  Large,  round  needles  are  also  used  in  work  upon  the 
liver,  kidneys  and  sometimes  the  uterus.  The  cutting  needle 
(either  straight  or  curved)  does  not,  necessarily,  differ  very 
greatly,  in  appearance,  from  the  round.  Its  use  is  primarily  in 
tissues  where  some  resistance  to  the  passage  of  the  needle  may 
be  expected  and  where  the  danger  from  causing  hemorrhages  or 
of  the  suture  tearing  out  is  slight.  The  cutting  quality  is  obtained 
by  the  type  of  point  and  cross-section.  We  have,  thus,  spear- 
pointed  needles;  the  triangular  sectioned  needle,  somewhat  like 
an  old-style  bayonet;  and  the  flattened  needle,  with  a  single, 
sharpened  cutting  edge  near  the  point.  The  degree  of  curve  of 
a  needle  may  vary  from  that  only  slightly  departing  from  the 
straight  to  that  which  is  almost  a  perfect  semicircumference  of  a 
small  circle.  In  addition  to  these  may  be  mentioned  the  large 
needles  and  ligature  carriers  that  unite,  in  one  instrument,  the 
functions  of  needle-holder  and  needle  (Fig.  111). 

6.  Auxiliary  Instruments. — The  number  of  instruments  sup- 


SURGICAL  INSTRUMENTS 


291 


292 


THE  OPERATION 


SURGICAL  INSTRUMENTS  293 

plementary  to,  but  not  definitely  identified  with,  the  above 
groups  covers  a  field  that  cannot  be  comprehensively  covered 
within  the  limits  of  a  single  chapter,  or  indeed  of  a  single  small 
book.  We  shall,  however,  make  a  brief  study  of  a  few  of  the  more 
important — those  in  general  and  frequent  use.  For  this  purpose, 
we  shall  consider  five  classes  of  instruments :  searchers,  directors, 
dissectors,  dilators  and  evacuators. 

A.  The  probes  are  the  truest  type  of  searchers  (Fig.   112, 
Nos.  1  and  2).    They  are  of  varying  size  to  permit  of  introduction 
in  passages  of  the  smallest  size  and  large  passages  whose  known 
dimensions  are  fairly  constant  and  ordinarily  of  a  fairly  soft 
metal  to  permit  of  shaping  by  hand  so  as  to  follow  the  curves 
of  the  passage.     Their  function  is  diagnostic, — the  exploration 
of  a  cavity  or  passage  that  is  not  subject  to  visual  or  digital 
examination. 

B.  The  directors  (Fig.  112,  Nos.  4  and  5)  are  a  less  commonly 
used  group,  somewhat  resembling  the  searchers  in  general  char- 
acteristics, but  supplied  with  a  grooved  track  along  which  the 
back  of  a  knife  or  scissors  blade  may  be  passed  accurately  in  a 
given  direction,  without  danger  of  additional  and  unintended 
injury  to  the  parts. 

C.  The  dissectors  (Fig.   112,  Nos.  6-8)   are    absolutely   or 
moderately  blunt-bladed  instruments,  used  in  the  careful  separa- 
tion of  tissues  in  regions  where  the  use  of  a  knife  or  scissors  might 
cause  unnecessary  or  objectionable  destruction  of  tissue. 

D.  The  dilators  (Figs.  113  and  114)  are  instruments  used  for 
the  purpose  of  enlarging  already  existing  orifices  either  as  a  means 
of  treatment  or  in  order  to  render  the  subjacent  parts  more 
readily  accessible.    They  may  be  graduated  in  size,  so  that  the 
introduction  of  successive  instruments  produces  gradual  dilata- 
tion; cone-shaped,  so  that  the  gradual  introduction  of  the  single 
instrument  produces  the  same  result;  or  bladed,  so  that  the 
gradual  separation  of  the  blades,  under  pressure,  procures  dila- 
tation.   Their  most  common  applications  for  curative  purposes 
are  to  strictures  of  the  resophagus,  urethra  and  rectum  and  dila- 
tation of  the  uterine  cervix  for  dysmenorrhcea.     For  purposes 
of  rendering  the  parts  more  accessible,  they  are  most  commonly 
employed  in  dilating  the  female  urethra,  the  sphincter  ani  and 
the  uterine  cervix  (in  the  last  case,  to  permit  thorough  curettage). 

E.  The  evacuators  (Figs.  115  and  116),  as  their  name  would 
suggest,  are  designed  to  remove  foreign  or  excessive  fluid  from 


SURGICAL  INSTRUMENTS  295 

body  cavities.  They  vary  from  the  simple  aspirating  needle 
(Fig.  116,  No.  1),  used  to  remove  fluid  from  joints  or  other  locali- 
ties, for  diagnostic  purposes,  to  the  heavy  trocar  and  cannula 
(Fig.  116,  Nos.  5-6)  used  for  evacuating  large  ovarian  cysts, 
before  removal,  and  include  the  various  catheters  (Fig.  115). 
The  trocar  and  cannula  consists  of  a  tube  (the  cannula)  which  is 
supplied  with  an  accurately  fitted,  pointed,  metal  core  (the  tro- 
car), the  point  of  which  projects  beyond  the  tube.  This  is  used 
by  forcing  the  point  through  the  cyst  wall  (or  even  the  abdominal 
wall),  removing  the  trocar  and  leaving  the  cannula  in  place, 
where  it  acts  as  a  tubular  drain. 

The  Care  of  Instruments. — The  first  requisite  of.  the  proper 
care  of  all  metal  surgical  instruments  is  that,  when  not  in  use, 
they  be  dry  when  put  away  and  that  they  be  kept  in  a  dry  place. 
After  using,  the  instruments  should  be  boiled  to  destroy  any 
infectious  material  that  may  have  adhered  during  operation. 
They  are  then  mechanically  cleansed  in  soap  and  water,  supple- 
mented, when  necessary,  for  the  removal  of  rust  or  firmly  ad- 
herent particles,  by  sand  soap,  Dutch  cleanser,  or  some  similar 
preparation.  After  cleaning,  they  are  carefully  dried  with  cloths, 
the  locks  lubricated  with  vaseline  or  some  thin  oil,  and  put  away 
in  a  dry  instrument  case.  When  instruments  are  used  only  at 
infrequent  intervals,  as  may  be  the  case  in  private  offices  or  with 
special  instruments,  it  is  well  to  apply  a  light  coat  of  some  thin 
oil,  after  drying.  Cutting  instruments  should  not  be  sterilized 
in  a  tray  with  numerous  other  instruments,  as  the  edges  may  be 
nicked  or  dulled  by  contact. 

Hollow  instruments  such  as  trocars  and  cannulse  and  hollow 
needles  for  hypodermic  and  aspirating  syringes  need  special  care 
to  prevent  plugging  of  the  tube  with  rust.  Absolute  alcohol 
should  be  run  through  such  instruments  after  thorough  cleansing, 
and  a  wire  smeared  with  oil  or  vaseline  should  always  be  inserted 
in  the  hollow  needles  before  putting  away.  Instruments  with 
elaborate  joints  should  receive  particular  attention  to  see  that 
no  moisture  remains  at  places  not  easily  accessible.  A  costly 
instrument  may  be  easily  ruined  by  carelessness  in  such  par- 
ticulars. 


CHAPTER  XXII 

THE  ASEPTIC  TECHNIC 
I.  DEFINITIONS 

THE  word  technic  means  the  correct  manner  of  procedure,  in 
all  of  its  minutest  details,  which  is  employed  in  the  proper 
carrying  out  of  any  piece  of  work  requiring  special  knowledge 
and  skill.  It  is,  in  other  words,  the  right  way  of  doing  things. 
Every  form  of  creative  or  manual  activity  in  which  man  applies 
himself,  including  even  art  and  literature,  has  its  own  technic; 
that  is,  the  right  way  of  doing  that  particular  thing.  An  error 
in  technic  is  a  departure  from  the  recognized  procedure  with 
the  result  of  a  decrease  in  efficiency,  or  a  failure  to  attain  the 
best  possible  result  in  the  final  product.  • 

Let  us  consider,  as  a  homely  illustration,  the  preparation  of 
food.  Every  one  knows  that  a  slight  and  to  the  novice  apparently 
insignificant  variation  in  the  manner  of  preparing  and  cooking 
an  article  of  food  may  make  all  the  difference  between  a  whole- 
some, appetizing  dish  and  a  nauseating  mess.  In  other  cases 
the  contrast  is  not  so  great.  One  way  of  cooking  will  produce  a 
dish  that  is  fairly  good,  while  a  slightly  different  way  will  add 
to  it  a  delicious  delicacy  of  flavor  infinitely  superior  to  the  other 
product.  Again,  there  may  be  several  ways  of  preparing  a  dish 
giving  results  a  little  different  but  about  equally  good.  Finally, 
there  will  be  cases  where  there  is  no  general  agreement,  even 
among  the  most  expert,  as  to  which  of  two  or  more  methods  is 
the  best. 

The  technic  of  general  surgery  covers  every  surgical  procedure, 
from  the  giving  of  a  hypodermic  to  the  most  extensive  surgical 
operation,  and  in  this  field  also  we  shall  find  the  same  differences 
as  those  indicated  in  our  illustration,  but  the  results  of  technical 
errors  will  be  vastly  more  serious.  In  the  first  case  we  shall  have, 
instead  of  a  spoiled  dish,  perhaps  prolonged  illness  or  even  loss 
of  life  of  a  patient  who,  if  things  had  been  done  for  him  in  the 
right  way,  would  have  had  every  chance  of  a  speedy  recovery. 
In  the  second  case  the  bad  results  of  the  use  of  the  less  efficient 
of  two  methods  may  not  be  so  obvious,  and  yet  very  serious  in 
296 


THE  ASEPTIC  TECHNIC  297 

reality,  since  in  comparing  a  long  series  of  operations  the  tech- 
nical error  may  show  its  effect  in  a  much  higher  mortality.  Of 
the  third  case,  where  several  methods  are  equally  good,  there 
are  many  instances  in  surgery,  and  there  are  also  not  a  few  under 
the  fourth  where  technical  details  are  still  a  matter  of  dispute. 

It  is  clear,  therefore,  that  the  technic  of  surgery,  like  that  of 
any  other  art  or  industry,  does  not  consist  of  a  set  of  cut-and- 
dried  rules  to  be  learned  by  rote.  Its  practice  requires  knowledge 
and  understanding  of  principles  and  causes  and  the  intelligent 
application  of  this  knowledge  to  particular  cases  under  widely 
different  conditions;  nor  is  it  rigid  and  unchangeable,  but  rather 
subject  to  constant  improvement  as  new  facts  and  methods  are 
discovered. 

In  the  technic  of  surgery  there  are  three  quite  distinct  divi- 
sions. The  first  is  the  aseptic  technic,  which  is  concerned  with 
the  methods  of  preventing  infection  in  wounds.  The  second 
part  of  the  operative  technic  relates  to  the  manner  of  performing 
the  operation  itself.  It  concerns  the  work  of  the  surgeon  almost 
exclusively.  Practically  all  that  concerns  the  work  of  the  nurse 
in  connection  with  it  is  contained  in  the  chapter  on  operative 
steps.  The  most  important  general  principles  of  operative  technic 
are  sharp  knife  dissection,  avoiding  tearing  of  the  tissues,  or  any 
unnecessary  trauma;  exposure  of  the  operative  field  with  the 
least  possible  mutilation  of  overlying  parts;  perfect  hsemostasis 
at  every  stage  of  the  operation;  avoidance  of  constriction  of  large 
masses  of  tissue  in  ligating  vessels ;  suturing  so  as  to  restore  proper 
anatomical  relations;  obliteration  of  dead  spaces;  avoidance  of 
undue  tension  in  closure.  Every  separate  operation  has  its  own 
technic,  the  result  of  constant  study  and  trial  to  find  the  most 
efficient  way.  The  path  of  surgery  is  strewn  with  discarded  bits 
of  operative  technic,  many  of  them  the  result  of  much  ingenuity 
and  labor,  which  have,  however,  been  found  wanting  in  some 
important  particular.  A  full  discussion  of  the  subject  would  con- 
stitute a  treatise  on  operative  surgery.  The  third  division  of  the 
surgical  technic  concerns  the  management  of  the  individual 
patient  before,  during  and  after  an  operation;  how  he  can  be 
brought  to  the  best  possible  condition,  both  physical  and  mental, 
to  meet  the  ordeal  that  is  before  him;  how  he  can  be  carried 
through  that  ordeal  with  the  least  risk,  the  minimum  amount  of 
suffering,  the  smallest  drain  upon  his  vital  forces,  and  how  he  can 
be  brought  to  full  restoration  of  health  in  the  shortest  possible  time. 


298  THE  OPERATION 

We1  have  defined  the  terms  infection  and  septic  infection  or 
sepsis  (page  17-18).  We  must  now  define  certain  related  words 
which  are  frequently  misused.  Disinfection  means  the  destruc- 
tion of  living  organisms  capable  of  causing  disease.  It  is  usually 
applied  to  articles  such  as  clothing,  for  example,  which  are  capable 
of  conveying  disease.  An  antiseptic  is  a  substance,  usually  a 
chemical  solution,  which  is  antagonistic  to  septic  bacteria,  either 
killing  them  or  rendering  them  harmless  by  preventing  them  from 
multiplying.  The  words  asepsis,  aseptic,  mean  the  absence  of 
sepsis.  A  wound  is  aseptic  when  it  does  not  become  septic,  or 
we  may  say  when  septic  bacteria  have  not  been  introduced  into 
it  in  sufficient  numbers  to  overcome  the  resistance  of  the  tissue 
cells.  Sterilization  means  the  absolute  destruction,  usually  by 
heat,  of  all  living  organisms,  upon  the  surface  of  or  within  any 
article  or  material. 

When  by  some  injurious  effect  brought  to  bear  upon  them, 
bacteria  are  not  killed  but  are  rendered  inert  or  inactive,  so  that 
they  cannot  grow  or  multiply,  at  least  for  a  time,  we  say  that 
they  are  "  inhibited."  The  effect  of  our  disinfectant  and  anti- 
septic solutions,  particularly  in  the  more  dilute  preparations,  is 
often  to  inhibit  bacteria  rather  than  to  kill  them. 

II.  THE  FIRST  PRINCIPLES  OF  ASEPSIS 

1.  Given  proper  coaptation,  or  fitting  together,  of  wounded 
tissues,  and  rest  (i.e.,  prevention  of  motion  in  the  wounded  part), 
almost  the  sole  remaining  obstacle  to  prompt  wound  healing  lies  in 
the  invasion  of  the  wound  by  one  of  about  half  a  dozen  species 
of  bacteria  known  as  the  septic  or  pyogenic  group.    When  these 
are  absent  wounds  heal  normally;  when  they  are  present  septic 
disease  results  in  the  wound,  delaying  healing  or  preventing  it 
altogether.     It  is  not  meant  that  the  presence  of  a  single  bac- 
terium of  any  of  these  species  will  cause  a  wound  to  suppurate. 
The  tissue  cells  are  able  to  destroy  a  certain  number  of  the  hos- 
tile invaders.    This  power  of  resistance  is  variable,  depending,  for 
example,  on  the  age  and  health  of  the  individual  and  particularly 
on  the  vascular ity  of  the  tissues  involved  in  the  wound. 

2.  All  men  and  all  the  higher  animals,  probably,  are  chronic 
carriers  of  this  group  of  bacteria,  and  everything  handled  by 
man  is  quite  certain  to  be  contaminated  with  them. 

3.  The  constant  dwelling  place  of  these  germs  is  upon  the 
skin  and  mucous  surfaces  of  the  body,  particularly  in  the  in- 


THE  ASEPTIC  TECHNIC  299 

testinal  canal  the  tissues   of   the   interior  of   the   body  being 
normally  free  from  them. 

4.  Although  it  is  possible  for  wounds  to  be  infected  in  several 
ways,  for  example  through  the  air,  or  through  the  blood  stream 
(since  bacteria  occasionally  find  their  way  into  the  blood  and 
may  survive  there  for  shoit  periods),  yet  practical  experience 
shows  that  almost  the  sole  cause  of  wound  infection  is  the  con- 
veyance of  bacteria  by  contact,  or  by  direct  implantation  into 
the  wound  of  some  germ-bearing  material. 

5.  Prevention  of  infection  in  wounds,  therefore,  requires  that 
everything  that  comes  in  contact  with  a  wounded  surface  must 
first  be  rendered,  as  far  as  possible,  sterile,  i.  e.,  entirely  free  from 
living,  single-celled  organisms. 

G.  The  most  efficient  means  of  sterilization  is  heat,  and  this 
should  be  the  method  employed  wherever  possible.  In  order 
to  sterilize  any  article  it  must  be  subjected  to  dry  heat  at  150°  C. 
(302°  F.)  for  one  hour,  or  to  steam  at  ordinary  pressure  for  one 
hour,  or  to  steam  at  fifteen  pounds  pressure  for  thirty  minutes, 
or  to  boiling  water  for  ten  minutes.  These  represent  the  minimum 
requirements  in  practical  work. 

7.  Any  object  that  has  been  sterilized  which  afterwards 
comes  into  even  momentary  contact  with  an  unsterilized  object 
thereby  ceases  to  be  sterile. 

8.  The  sterilization  of  the  skin  is  the  most  difficult  problem 
in  the  aseptic  technic,  because  the  application  of  heat  as  a  steril- 
izing agent  is  impracticable  and  because  bacteria  are  contained 
in  the  crypts  of  the  skin  glands  and  follicles,  where  disinfecting 
solutions  cannot  readily  reach  them. 

9.  The  sources  from  which  bacteria  can  enter  an  operative 
wound  are :    (a)  The  instruments  used,    (b)  The  gauze  sponges 
or  swabs  which  are  used  to  absorb  blood  in  the  wound,     (c) 
Any  solutions  which  may  be  used,     (d)  Ligatures  and  sutures, 
(e)  The  dressings,    (f)  The  hands  of  the  surgeon,  assistants  and 
nurses,    (g)  The  skin  of  the  patient,    (h)  The  air.    (i)  The  blood 
stream  or  the  lymphatics. 

10.  Heat  can  be  employed  as  the  means  of  sterilization  for 
all  these  items  from  (a)  to  (e) .    The  hands  can  be  covered  by  non- 
porous  (rubber)  gloves  which  can  be  sterilized  by  heat.    For  the 
patient's  skin  the  best  that  can  be  done  is  to  cleanse  and  apply  a 
not  too  irritating  antiseptic  (tincture  of  iodine)  and,  after  the 
incision  is  made,  cover  the  skin  with  sterile  material. 


300  THE  OPERATION 

III.  STERILIZATION  BY  HEAT 

The  only  reliable  method  by  which  objects  or  material  can 
be  sterilized  within  a  short  time,  measured  in  minutes,  is  by  the 
application  of  heat  in  some  form.  Dry  heat  means  heating  in 
the  air,  as  in  an  oven.  Moist  heat  may  be  employed  in  the  form 
of  water  or  of  steam.  Steam  may  be  employed  either  as  free 
flowing  steam  or  confined  under  pressure  in  a  closed  air-tight 
chamber. 

The  factors  which  must  be  taken  into  account  in  sterilizing 
by  heat  are,  (1)  the  susceptibility  of  the  organisms  to  be  killed, 
(2)  the  degree  of  temperature  to  be  employed,  (3)  the  time  of 
exposure,  (4)  the  presence  of  moisture,  and  (5)  the  liability  of  the 
articles  to  be  sterilized  to  be  themselves  affected  by  heat.  Bac- 
teria in  the  active  or  "  vegetative  "  stage  are,  as  has  been  said, 
killed  at  a  comparatively  low  temperature;  but  bacteria  in  the 
resting  stage,  i.e.,  the  spore-forming  bacteria,  resist  the  tempera- 
ture of  boiling  water  or  free  steam  for  more  than  an  hour.  In 
sterilizing  culture  media  in  the  laboratory  a  method  known  as 
"  fractional  "  or  "  discontinuous  "  sterilization  is  used  in  order 
to  make  sure  of  the  destruction  of  the  spore-forming  organisms. 
This  consists  in  repeating  the  sterilizing  process  for  three  days 
in  succession,  the  object  being  to  allow  the  spores  which  may  be 
present  to  grow  out  into  the  vegetative  form  during  the  intervals 
between  the  successive  sterilizations,  they  being  then  readily 
killed  when  heat  is  next  applied.  This  method  applies  only  to 
liquids  or  moist  materials,  since  spores  will  not  grow  out  when  dry. 

The  higher  the  temperature  the  less  the  time  of  exposure 
needed.  The  temperature  of  the  flame  kills  bacteria  instantly, 
but  most  objects  to  be  sterilized  would  themselves  be  destroyed 
by  such  high  temperatures.  We  have  to  determine  the  time  of 
exposure  therefore  in  accordance  with  the  degree  of  heat  that 
can  be  safely  used.  Dry  heat  will  scorch  or  injure  most  materials 
at  a  higher  temperature  than  from  150°  to  180°  C.  (365°  F.).  An 
exposure  of  an  hour  to  dry  heat  at  this  temperature  is  necessary 
to  destroy  spore-forming  bacteria.  Dry  heat  does  not  penetrate 
easily  into  packages  of  woven  goods. 

Moist  heat  is  more  efficient  than  dry  heat  as  a  sterilizing 
agent,  i.e.,  at  the  same  temperature.  Thus  moist  heat  at  100°  C. 
(212°  F.),  which  is  the  highest  temperature  we  can  obtain  from 
boiling  water,  or  free  steam,  is  about  equal  in  sterilizing  power, 
with  the  same  time  of  exposure  to  dry  heat  at  150°  C. 


THE  ASEPTIC  TECHNIC  301 

To  obtain  the  most  efficient  sterilization  by  means  of  heat 
we  must  employ  moist  heat,  in  the  form  of  steam,  at  a  higher 
temperature  than  100°  C.,  and  to  do  this  it  is  necessary  to  apply 
the  steam  under  pressure  in  an  air-tight  and  steam-tight  chamber. 
The  apparatus  employed  for  this  purpose  is  known  as  a  pressure 
sterilizer  or  autoclave. 

The  temperature  at  which  water  boils,  and  therefore  the 
temperature  of  the  steam  given  off,  depends  on  the  pressure  upon 
the  water  surface.  In  the  open  air  this  pressure  is  due  to  the 
weight  of  the  atmosphere,  as  is  shown  by  the  fact  that  water 
boils  at  a  lower  temperature  at  high  altitudes  than  at  the  sea 
level.  When  water  boils  in  a  closed  chamber  the  steam  given 
off  itself  rapidly  increases  the  pressure  on  the  surface  of  the  water. 
When  the  pressure  at  a  given  temperature  becomes  just  sufficient 
to  check  the  further  giving  off  of  vapor  from  the  surface,  the 
space  above  the  water  is  said  to  be  saturated  with  steam.  Now 
if  the  water  is  further  heated  more  vapor  will  be  given  off,  and 
the  pressure  will  be  increased.  The  atmospheric  pressure  at 
sea  level  is  about  15  pounds  to  the  square  inch;  if  we  add  another 
18  pounds  of  pressure,  the  temperature  of  the  saturated  steam 
in  the  autoclave  will  be  about  275°  F.,  or  135°  C.  Moist  heat  at 
this  temperature  will  kill  all  bacteria,  including  spores,  after  an 
exposure  of  twenty  minutes.  This  is  about  the  temperature  used 
in  the  operating  room  for  the  sterilization  of  dressings  and  other 
materials.  So  long  as  the  steam  is  in  contact  with  the  surface 
of  the  water  the  closed  space  will  be  filled  with  saturated  steam, 
whatever  the  temperature  may  be.  But  if  the  steam  is  cut  off 
from  the  surface  of  the  water,  or  the  water  is  all  boiled  away, 
and  if  then  the  steam  is  still  further  heated,  its  condition  changes, 
it  becomes  "  dry  "  steam  and  its  sterilizing  power  will  then  be 
only  equal  to  that  of  dry  air  at  the  same  temperature, 

IV.  OUTLINES  OF  THE  ASEPTIC  TECHNIC 

1.  Methods  of  Sterilization. — The  various  methods  in  prac- 
tical use  and  the  manner  of  using  them  have  already  been  de- 
scribed. It  is  sufficient  here  to  present  a  summary  of  their  appli- 
cation to  the  sterilization  of  the  different  materials  employed  in 
operative  work. 

(1)  Articles  to  be  Sterilized  by  Steam. — Covers  for  the  operating 
and  instrument  tables  (rubber  sheets  and  cotton  sheets);  sheets 
and  towels  to  drape  and  cover  the  patient's  body,  except  the 


302  THE  OPERATION 

field  of  operation;  gowns,  masks,  and  caps  for  the  operator  and 
assistants;  sponges,  packs,  silk  and  linen  sutures,  and  ligatures; 
gauze  for  dressings;  flasks  of  saline  solution,  olive  oil  for  lubri- 
cating catheters,  camphorated  oil  for  hypodermic  use,  vaseline, 
zinc  ointment,  etc.;  rubber  gloves,  catheters  and  drainage  tubec. 

(2)  Articles   to   be   sterilized   by   Boiling   in  Water,    or    One 
Per  Cent.  Solution  of  Carbonate  of  Soda  (Washing  Soda). — All 
metal  instruments  (except  the  cystoscope);  sealed  glass  tubeo 
containing    catgut    and    kangaroo    tendon    sutures    and    liga- 
tures furnished  by  the  manufacturers;  glass  catheters;    basins 
and  irrigators. 

(3)  Articles  to  be  Sterilized  by  Dry  Heat. —  Glassware;  catgut 
(in  preparation). 

(4)  Articles  to  be  Sterilized  by   Chemical  Solutions. — Gutta- 
percha  tissue  (in  1  to  1000  bichloride  of  mercury  solution) ;  skin 
of  the  patient  in  the  field  of  operation  (iodine  and  alcohol,  or 
bichloride  solution) ;  hands  of  the  operator  and  assistants  (alcohol, 
bichloride   solution,   permanganate   of  potash  and  oxalic  acid 
solutions,  etc.);  gum  catheters  (bichloride);   Kelly  pads  (1-20 
carbolic). 

(5)  Articles  to  be  Sterilized  by  Formalin  Vapor. — Cystoscopes; 
gum  catheters;  and  perhaps  a  few  other  special  instruments. 

2.  Assembling  and  Handling  the  Sterilized  Outfit.— The 
various  articles  required  for  an  operation,  sponges,  packs,  dress- 
ings, towels,  sheets,  etc.,  are  put  up  in  individual  packages 
before  they  are  sterilized,  and  the  total  requirements  for  a  single 
operation  (i.e.,  all  those  that  are  to  be  sterilized  by  steam)  are 
assembled  in  one  or  two  large  packages  or  drums.  In  these 
they  are  carefully  arranged  in  due  order,  those  that  are  to  be 
used  first  on  top  and  those  that  will  be  needed  later  at  the  bottom, 
so  that  there  need  be  no  pulling  about  of  the  various  articles  to 
get  what  is  wanted  at  any  time.  First,  towels  and  sheets  for 
covering  instrument  and  dressing  table;  next,  nurses'  and  opera- 
tors' gowns,  caps  and  masks,  covers  for  the  operating  table, 
operating  sheet  with  hemmed  opening  in  centre;  lastly,  towels 
for  surrounding  the  field  of  operation.  Articles  which  are  to 
come  into  contact  with  the  wound  itself,  sponges,  packs,  and 
dressings,  may  be  in  a  separate  drum  or  package.  All  sponges 
and  packs  should  be  counted  twice,  preferably  by  two  nurses 
separately,  at  the  time  they  are  put  up,  all  packages  containing 
the  same  number.  The  time  for  sterilization  of  this  outfit  should 


THE  ASEPTIC  TECHNIC  303 

be  arranged  so  that  it  will  be  ready  shortly  before  the  operation. 
In  the  steam  sterilizer  the  packages  or  drums  should  be  subjected 
to  ten  minutes'  vacuum,  thirty  minutes'  steam,  followed  by  ten 
minutes'  vacuum.  Instruments  and  all  articles  that  are  sterilized 
in  boiling  water  are  arranged  in  a  tray  in  the  instrument  sterilizer, 
boiled  ten  minutes,  and  brought  direct  to  the  instrument  table 
in  the  tray,  from  which  they  are  taken  by  the  nurse  and  placed 
on  the  table  in  proper  order. 

The  operating  force  is  divided  into  two  groups:  the  clean 
group,  consisting  of  the  operating  surgeon,  two  assistants,  and 
one  or  two  nurses;  and  the  not-sterile  group,  consisting  of  the 
anaesthetist,  one  or  two  nurses,  and  an  orderly.  Each  member 
of  the  clean  group,  after  being  cleaned  up,  gowned  and  gloved, 
must  see  to  it  that  no  part  of  his  clothing  comes  in  contact  with 
any  article  that  has  not  been  sterilized,  particular  care  being 
taken  that  the  hands  touch  nothing  not  surgically  clean.  The 
first  lesson  to  be  learned  is  that  the  face  is  never  surgically  clean. 
All  handling  of  unsterile  articles  is  done  by  the  not-sterile  group, 
all  handling  of  sterile  articles  by  the  clean  group.  Thus,  packages 
are  opened  by  the  unscrubbed  nurse,  their  contents  are  removed 
by  the  clean  nurse. 

3.  Preparation  of  Members  of  the  Clean  Group. — Two  points 
are  to  be  considered  here:  (1)  the  cleansing  and  disinfection  of 
the  hands,  and  (2)  the  manner  of  putting  on  the  sterilized  gowns, 
gloves,  masks  and  caps.  The  methods  in  use  for  hand  disinfec- 
tion vary  according  to  individual  ideas.  All  the  methods  include 
the  two  steps  of  thorough  scrubbing  with  soap  and  water  for  ten 
minutes,  followed  by  immersion  in  some  antiseptic  solution  for 
five  minutes  or  more,  for  example,  in  70  per  cent,  alcohol  (one 
minute)  and  1-1000  bichloride  (five  minutes).  One  point  already 
referred  to  needs  particular  emphasis.  There  is  a  great  deal  of 
difference  in  the  susceptibility  of  the  'skin  of  different  individuals 
to  the  irritating  effects  of  antiseptic  solutions.  When  any  such 
solution  makes  the  skin  of  the  hands  rough  it  is  an  error  in  teclinic 
for  that  individual  to  continue  the  use  of  that  solution.  The 
same  is  true  of  the  use  of  the  scrubbing  brush.  A  piece  of  gauze 
is  equally  efficient  for  hand  cleansing,  and  should  be  used  instead 
of  the  brush  whenever  the  latter  is  a  source  of  irritation.  Super- 
latively clean  hands  are  a  necessity,  but  an  irritated  skin  is  a 
greater  source  of  danger  than  the  failure  to  use  strong  antiseptics. 
Alcohol  at  least  can  always  be  used. 


304  THE  OPERATION 

The  preparation,  sterilization  and  putting  on  of  rubber  gloves 
is  an  important  part  of  the  technic.  The  hands  cannot  be 
sterilized.  That  they  can  be  made  fairly  aseptic  is  undeniable, 
since  the  triumph  of  aseptic  surgery  was  assured  before  rubber 
gloves  came  into  use.  There  are  pitfalls  in  their  use  that  must  be 
avoided.  A  glove  with  even  a  minute  hole  in  it  is  perhaps  worse 
than  no  glove  at  all.  They  can  easily  be  contaminated  while 
putting  them  on,  or  by  many  things  that  can  happen  during  an 
operation,  such  as  a  needle  puncture,  a  drop  of  perspiration, 
accidental  contact  with  unsterile  things,  or  necessary  contam- 
ination when  a  viscus  is  opened.  In  these  cases  fresh  gloves 
should  be  ready  for  the  change  that  must  be  made. 

The  preparation  of  gloves  for  an  operation  consists  in  clean- 
sing, testing  for  punctures  and  sterilizing.  The  test  for  punctures 
is  best  made  by  partly  filling  the  glove  with  water,  which  can  be 
put  under  pressure  by  folding  over  the  open  end  and  pinching 
between  the  fingers.  If  the  outside  is  dry  the  smallest  puncture 
will  show  by  a  drop  of  moisture.  After  final  washing  in  clean 
hot  water  the  gloves  are  cuffed,  wrapped  and  sterilized  by  steam 
at  250°  F.  (15  Ibs.  pressure)  for  30  minutes.  The  vapor  is  then 
withdrawn  and  the  gloves  dried  at  the  same  temperature  for 
30  minutes. 

In  putting  on  dry  gloves  a  lubricant  is  necessary,  either  sterile 
dry  powder  or  glycerite  of  starch  paste.  The  clean  nurse  must 
perforce  put  on  gloves  without  assistance.  The  outside  of  the 
glove  must  not,  of  course,  touch  the  bare  skin  of  the  hand.  The 
gloves  in  the  sterilizing  package  are  cuffed  by  folding  the  edges 
forward  towards  the  fingers.  The  fingers  and  thumb  of  the  right 
hand  grasp  this  cuff  in  putting  on  the  left  glove.  The  fingers  of 
the  gloved  left  hand  are  then  slipped  under  the  cuff  in  putting  on 
the  right  glove.  When  the  surgeon  is  cleaned  up  and  ready 
the  clean  nurse  hands  him  his  sterile  gown  which  is  held  at 
arm's  length  while  it  is  unfolded  and  the  hands  slipped  into  the 
armholes;  the  arms  are  then  held  straight  in  front  while  the  un- 
scrubbed  nurse  pulls  the  gown  into  place  by  means  of  the  tapes, 
which  are  then  tied  at  the  back.  The  clean  nurse  hands  the  sur- 
geon a  sterile  towel,  and  drenches  his  hands,  after  he  has  dried 
them,  with  sterile  powder.  She  then  picks  up  a  glove,  slips  the 
fingers  of  both  hands  under«the  cuff,  on  opposite  sides,  and  spreads 
the  glove  wide  open  while  the  surgeon  thrusts  his  hand  into  it, 
repeating  the  process  for  the  other  hand.  Finally  she  ties  the 


THE  ASEPTIC  TECHNIC  305 

sleeves  of  his  gown  at  the  wrists  and  adjusts  the  gloves  over  them. 
The  same  is  done  for  the  other  members  of  the  clean  group. 
The  unscrubbed  nurse  adjusts  and  ties  the  caps  and  masks. 
The  toilet  of  the  patient,  who  may  be  considered  a  member  of  the 
clean  group,  consists  of  two  steps :  disinfection  of  the  skin  in  the 
field  of  operation  and  covering  all  the  rest  of  the  body  except  the 
face  with  sterile  sheets  and  towels.  Tincture  of  iodine  diluted  with 
alcohol  is  now  almost  universally  used  for  skin  disinfection  in  the 
field  of  operation.  The  first  thing  to  be  remembered  is  that  the 
skin  should  be  absolutely  dry.  Scrubbing  with  soap  and  water 
should  be  done  on  the  previous  day,  as  should  also  the  shaving. 
If  it  is  necessary  to  shave  immediately  before  the  operation  this 
should  be  done  dry  with  the  use  of  benzene.  The  skin  should  also 
be  free  from  grease,  and  to  this  end  a  preliminary  washing  with 
some  oil  solvent  (ether,  turpentine,  benzene)  may  be  employed. 
The  method  employed  at  the  Mayo  clinic,  copied  from  that  in  use 
at  the  clinic  of  Dr.  Bastianelli  in  Rome,  consists  of  applying  two 
solutions  to  the  skin.  The  skin  is  first  lightly  rubbed  with  a 
solution  consisting  of  one  part  of  iodine  crystals  to  1000  parts 
of  benzene.  Tincture  of  iodine,  diluted  one-half  with  alcohol, 
is  then  painted  over  the  skin.  One  coat  is  enough.  A  wide  area 
about  the  proposed  wound  should  be  covered.  Blisters  may 
result  in  skin  creases  if  the  solution  is  allowed  to  run  into  them 
and  dry  slowly.  Bichloride  or  other  antiseptic  watery  solution 
should  never  be  employed  to  supplement  the  iodine  disinfection, 
for  blistering  is  sure  to  follow  if  this  is  done.  At  the  close  of  the 
operation  the  iodine  is  washed  off  with  alcohol  to  which  a  few 
drops  of  an  alkali  (soda,  potassa,  ammonia)  have  been  added.  To 
drape  the  patient,  towels  are  first  arranged  about  the  field  of 
operation;  the  operating  sheet  with  its  hemmed  opening  then 
covers  the  entire  body  of  the  patient  except  his  head;  finally, 
four  towels  are  arranged  about  the  opening  in  the  sheet.  After 
the  incision  is  made  through  the  skin  towels  are  fastened  to  the 
skin  edges  with  towel  clamps  so  that  none  of  the  skin  surface 
is  left  exposed. 

Every  worker  in  the  operating  room  must  develop  the 
aseptic  sense — a  second  nature  so  ingrained  that  a  slip  becomes 
as  unthinkable  as  a  gross  breach  of  good  breeding.  Moreover 
it  is  the  duty  of  any  member  of  the  team  to  call  attention  to  a 
break  that  might  be  overlooked. 

4.  Conduct  During  the  Operation. — It  goes  without  saying 


306  THE  OPERATION 

that  the  same  care  must  be  continued  to  avoid  contact  with 
unsterile  articles,  particularly  by  the  hands.  If  accidental 
contact  with  the  hands  occurs  the  gloves  should  be  changed. 
This  should  also  be  done  if  a  glove  is  perforated  by  a  knife  or 
needle  during  the  course  of  the  operation.  Instruments  that 
touch  anything  not  sterile  should  be  instantly  discarded  and 
resterilized  by  boiling  before  being  used  again.  When  any  hollow 
viscus  (stomach,  intestines,  appendix,  gall-bladder,  urinary 
bladder,  ureter,  pelvis  of  the  kidney)  has  been  opened  in  the 
course  of  an  operation,  all  instruments  that  have  been  used  within 
the  cavity  of  the  viscus  and  the  needles  and  sutures  employed  in 
its  closure  are  contaminated  and  should  never  be  replaced  among 
the  other  clean  instruments,  or  handed  back  to  the  surgeon  for 
use  in  a  later  stage  of  the  operation,  for  instance  in  closure  of 
the  wound.  Such  instruments  should  be  discarded  as  soon  as 
the  surgeon  has  finished  using  them,  and  the  instrument  nurse 
should  avoid  touching  them  with  her  gloved  hands.  Towels 
about  the  wound  should  be  changed  when  they  are  soiled  or,  in 
any  case,  before  the  wound  is  sutured.  Strict  count  must  be  kept 
of  packs  and  sponges  so  that  none  may  be  left  in  the  wound. 

5.  Conduct  Between  Operations. — Every  operation  is  a  thing 
by  itself.  A  complete  new  outfit  is  required  for  each  operation, 
no  part  of  the  preparation  for  a  previous  operation  being  carried 
over  for  the  next.  The  long  hand  scrubbing  need  be  done  only 
once  on  each  operating  day,  its  repeated  performance  being  too 
severe  upon  the  skin,  but  fresh  sterile  gloves  must  be  put  on 
for  each  operation.  Care  of  the  operating  room  has  been  de- 
scribed elsewhere.  Its  chief  requirement  is  strict  cleanliness, 
without  too  much  reliance  upon  the  antiseptic  solutions  used  to 
wipe  the  articles  of  furniture.  Accumulations  of  dust  in  forgotten 
places  to  be  blown  about  in  the  air  must  not  be  permitted.  Open- 
air  ventilation  is  desirable,  but  all  windows  should  be  screened. 
Flies  and  other  insects  must  be  absolutely  excluded,  For  all 
who  take  part  in  the  work  of  the  surgical  operating  room  the 
obligation  of  habitual  personal  cleanliness  arises  from  reasons 
more  imperative  than  the  standards  of  good  breeding.  Particular 
care  should  be  taken  of  the  hands.  The  nails  should  be  attended 
to  and  should  neither  be  allowed  to  grow  too  long  nor  be  cut  too 
short.  Suppurating  wounds  or  the  dressings  from  them  should 
never  be  handled  without  gloves.  The  mouth  and,  particularly, 
the  teeth  should  receive  scrupulous  attention.  Neglect  of  the 


THE  ASEPTIC  TECHNIC  307 

dentist  is  a  serious  error  in  the  aseptic  technic.  After  being  used 
in  an  operation  all  instruments  and  basins  must  be  resterilized 
by  boiling  in  water  before  being  put  away,  and  before  they  art 
used  in  another  operation. 

V.  THE  SUPER-TECHNIC 

The  aseptic  technic  presented  in  the  foregoing  outline  repre- 
sents in  substance  that  which  is  now  in  use  in  the  majority  of 
operating  rooms.  There  are,  of  course,  some  variations  in  minor 
details.  Considered  from  the  theoretical  standpoint  this  technic 
falls  very  far  short  of  the  standards  of  perfection.  Experience 
shows,  however,  that  it  is  sufficient  to  insure  the  absence  of 
septic  infection  in  the  great  majority  of  clean  operative  wounds. 
A  perfect  technic  is  probably  impossible  at  the  present  time,  and 
it  may  be  here  pointed  out  that  super-refinements  in  minor  de- 
tails, applied  haphazard  here  and  there,  do  not  as  a  rule  bring 
us  measurably  nearer  that  goal.  There  are,  however,  some  classes 
of  operations  where  the  tissues  involved  are  peculiarly  liable  to 
infection,  and  where,  moreover,  infection  is  particularly  disastrous. 
The  principal  operations  of  this  group  are  those  that  involve  the 
opening  of  the  larger  joints,  the  transplanting  of  tendons,  and 
the  so-called  open  operations  for  fractures.  In  these  cases 
experience  seems  to  justify  certain  additional  precautions  and 
the  adoption  for  these  particular  cases  of  what  may  be  called 
a  super-technic. 

Instruments,  sponges,  sutures  and  ligatures  are  given  a 
double  sterilization  time.  Silk  or  linen  sutures,  sometimes  used 
for  artificial  extension  of  tendons  in  transplanting,  are  boiled 
for  an  hour  in  bichloride  solution.  The  knife  used  for  the 
primary  skin  incision  is  laid  aside  and  a  new  knife  used  for  the 
deep  dissection.  As  soon  as  the  skin  is  incised  particular  care  is 
taken  in  fastening  towels  by  means  of  clamps  to  the  subcutaneous 
tissue  so  as  to  cover  all  the  skin  and  its  cut  edges.  Only  instru- 
ments and  sponges  are  allowed  to  enter  the  wound,  the  gloved 
hands  being  kept  altogether  out  of  it.  The  gloves  do  not  touch 
that  part  of  an  instrument  which  enters  the  wound.  The  instru- 
ment nurse,  therefore,  must  pick  up  instruments  only  by  the 
handles,  and  in  handling  ligatures  and  sutures  she  must  use 
instruments  altogether,  not  touching  them  with  her  gloved  hands. 
In  threading  a  needle  she  picks  up  the  needle  with  one  clamp 
and  the  thread  with  another.  She  prepares  short  ligatures,  (t> 


308  THE  OPERATION 

inch),  with  a  clamp  on  each  end  by  means  of  which  the  surgeon 
ties  the  vessels  without  touching  the  thread, 

VI.    BREAKS  IN  THE  ASEPTIC  TECHNIC 

We  have  emphasized  the  importance  of  a  rigid  adherence 
to  the  aseptic  technic  in  every  smallest  detail.  The  strength  of 
this  obligation,  in  fact,  cannot  be  overstated.  And  yet,  as  we 
have  pointed  out,  there  are  (from  a  theoretical  standpoint)  a 
number  of  weak  places  in  the  aseptic  precautions  as  now  prac- 
tised. We  ignore  infection  from  the  air.  We  cannot  sterilize 
the  skin.  Septic  bacteria  may  be,  and  probably  sometimes  are, 
carried  to  the  wounded  tissue  through  the  blood  stream.  It  is 
true,  also,  that  wounds  frequently  heal  without  suppuration  in 
spite  of  rather  glaring  departures  from  the  accepted  standards 
of  aseptic  practice.  These  facts  seem  to  furnish  a  reasonable 
excuse  for  a  certain  amount  of  carelessness  and  indifference. 
Since  wounds  may  suppurate  in  spite  of  all  precautions,  and 
since  some  do  not  suppurate  when  precautions  are  neglected, 
what  is  the  necessity  for  all  this  trouble?  The  most  convincing 
answer  to  this  question  lies  in  an  appeal  to  the  teachings  of 
experience.  The  aseptic  technic  as  we  have  it  is  the  result  of  a 
vast  amount  of  scientific  and  practical  study  extending  over  a 
period  of  many  years.  The  most  striking  result  has  been  the 
demonstration  of  the  immense  preponderance  of  the  danger  of 
infection  by  contact  or  implantation  over  all  other  forms.  Experi- 
ence proves  conclusively  that  the  means  we  have,  if  properly 
carried  out,  are  adequate  to  prevent  infection  in  practically  all 
clean  operative  wounds.  Suppuration  in  a  wound  from  unavoid- 
able causes  is  so  rare  that  in  no  single  instance  have  we  the  right 
to  assume  that  the  infection  was  not  due  to  a  technical  error. 
Whenever  in  a  hospital  a  series  of  infected  wounds  occurs  we 
may  be  certain  that  there  is  somewhere  a  broken  link  in  the 
chain  of  precautions  against  contact  infection  which  will  reveal 
itself  to  a  sufficiently  rigid  investigation.  Obviously,  then,  the 
utmost  vigilance  should  be  exercised,  at  all  times,  to  forestall 
any  such  unfortunate  occurrence. 

It  is  impossible  to  enumerate  all  the  possible  breaks  in  the 
technic.  It  is  needless  to  repeat  such  old  stock  illustrations  as 
that  of  a  nurse  picking  up  an  instrument  from  the  floor  or  of  a 
surgeon  holding  an  instrument  in  his  teeth.  Such  gross  breaks 
do  not  occur  any  longer,  if  indeed  they  ever  did.  The  technical 


THE  ASEPTIC  TECHNIC  309 

errors  which  still  occasionally  appear  are  far  more  subtle  and 
complex  in  character.  It  will  be  best,  perhaps,  to  illustrate  the 
subject  with  a  few  actual  instances.  It  should  be  said  at  the 
outset  that  these  happened  in  different  hospitals  and  in  different 
cities,  the  actual  place,  in  the  cases  selected,  being  unknown  to 
the  writers  themselves.  It  is  probable  that  the  same  things  have 
happened  in  a  number  of  institutions.  The  instances  are  true 
in  substance,  although  as  they  are  related  from  memory  accuracy 
in  details  is  not  vouched  for. 

In  a  large  hospital,  during  a  period  of  one  month,  there 
occurred  some  twenty  cases  of  infection  in  wounds.  The  majority 
were  insignificant  stitch  abscesses;  in  other  cases  the  entire 
wound  broke  down  and  suppurated  freely;  there  were  a  few 
c*ases  of  severe  sepsis;  one  died.  On  investigation  it  was  found 
that  a  new  force  of  nurses  had  been  assigned  to  the  operating 
room  at  the  beginning  of  the  month.  These  inexperienced  nurses 
had  been  put  in  charge  of  the  autoclave  without  sufficient  instruc- 
tion in  its  use.  After  placing  the  goods  in  the  chamber  and  closing 
the  door,  the  vacuum  valves  had  not  been  opened  to  remove  the 
air  from  the  chamber  before  turning  in  the  steam.  As  a  result 
none  of  the  sponges,  packs  or  dressings  used  during  this  period 
had  been  properly  sterilized. 

In  another  hospital  a  large  number  of  stitch  abscesses  oc- 
curred; a  few  of  the  infections  were  rather  severe,  but,  fortunately, 
there  were  no  fatalities.  Bacteriological  examinations  showed 
that  in  every  instance  the  colon  bacillus  was  one  of  the  organisms 
present.  The  colon  bacillus,  it  will  be  remembered,  is  a  normal 
inhabitant  of  the  intestinal  canal.  An  investigation  disclosed 
the  fact  that  in  some  of  the  wards  of  the  hospital  the  preparation 
of  the  patients  for  operation  had  been  done  in  a  hasty  and  careless 
manner.  The  giving  of  the  enema  was  frequently  postponed 
till  the  last  minute,  many  of  the  patients  going  to  the  operating 
room  before  a  satisfactory  result  had  been  obtained.  As  a  result 
soiling  of  the  operating  table  with  liquefied  fecal  matter  was  a 
rather  common  occurrence.  The  orderly  who  carefully  cleaned 
up  afterwards,  using  the  customary  antiseptic  solutions,  was 
observed  to  wipe  the  instrument  tables  with  the  same  cloth. 

A  surgeon,  having  observed  a  few  unexpected  infections 
following  some  of  his  operations,  suspected  that  something  was 
amiss  in  the  technic  in  his  operating  room.  He  could  find  nothing 
wrong,  so  he  asked  a  competent  friend  to  see  what  he  could 


310  THE  OPERATION 

discover.  The  friend  arrived  in  the  operating  room  an  hour 
before  the  operation  and  watched  the  preparation.  He  could 
find  nothing  to  criticise  except  in  one  particular.  The  instru- 
ment nurse  was  the  unfortunate  possessor  of  a  very  delicate 
skin.  Her  hands  were  rough  and  sore  as  a  result  of  the  rigorous 
hand  disinfection  which  was  insisted  upon.  This  condition  was 
aggravated  by  prolonged  wearing  of  the  rubber  gloves  which  were 
required  to  be  put  on  while  filled  with  bichloride  solution.  In 
order  to  save  her  hands  as  much  as  possible  she  opened  the  packs 
and  sponges  and  distributed  the  instruments  with  bare  hands, 
putting  on  the  gloves  at  the  last  moment  before  the  operation. 
It  is  probable  that  such  a  break  as  this  would  not  have  led  to 
results  sufficient  to  arouse  the  suspicion  of  the  surgeon,  except 
for  the  inflamed  condition  of  her  hands,  which  encouraged  the 
growth  of  septic  bacteria  upon  them  in  spite  of  the  disinfecting 
solutions  which  were  employed.  ' 

The  few  random  instances  here  cited  show  how  widespread 
may  be  the  origin  of  breaks  in  the  aseptic  technic.  The  fault 
in  one  case  is  traced  to  insufficient  preparation  in  the  ward  and 
a  later  careless  technic  by  the  operating  orderly.  Another  series 
of  infections  was  due  to  the  sterilization  of  dressings  by  insuffi- 
ciently instructed  nurses.  A  third  series  found  its  origin  in  the 
hands  of  the  instrument  nurse  herself.  Other  cases  might  easily 
be  given  where  the  fault  lay  with  the  surgeon  alone,  or  when  it 
was  traceable  to  weakness  in  other  links  in  the  aseptic  chain. 
With  such  results  before  us  in  the  form  of  concrete  instances, 
it  is  clear  that  there  is  little  present  danger  of  over-refinement  or 
over-emphasis  of  this,  the  most  important  single  development 
of  modern  surgery. 


CHAPTER  XXIII 

PREPARATION  FOR  AN  OPERATION  AND  THE 
OPERATING-ROOM  PERSONNEL 

I.  PREPARATION  OF  THE  OPERATING  ROOM 

1.  Necessary  Equipment. — In  considering  the  question  of  the 
necessary  equipment  along  any  line,  the  subject  should  be  intro- 
duced with  the  caution  that  lists  of  implements  or  materials 
should  not  be  systematically  memorized,  as  this  process  is  not 
only  an  unnecessary  strain  upon  the  memory,  but  is  almost 
sure  to  lead  to  the  forgetting  of  something.  The  question  should 
always  be  approached  with  a  definite  understanding  of  the 
requirements  of  the  occasion  and  then  treated  logically  and  by  a 
process  of  systematized  reasoning.  Such  will  be  our  endeavor 
in  this  and  subsequent  similar  descriptions,  in  order  to  demon- 
strate the  greater  ease  and  reliability  of  this  method  over  the 
memory-taxing  one. 

A.  For  the  Patient. — An  operating  table.     A  tray  with  the 
necessary  articles  for  preparing  the  field  of  operation  and  for 
catheterizing.    The  necessary  sterile  towels  and  covers. 

B.  For  the  Anoesthetist. — A  stool  upon  which   to   sit  while 
giving  the  anaesthetic.    A  stand  holding  the  necessary  anaesthetic 
supplies,  towels,  hypodermic  outfit,  etc.     A  stand  prepared  for 
the  subcutaneous  administration  of  salt  solution. 

The  stand  for  the  anaesthetist  should  contain:  (1)  ether  mask, 
freshly  covered;  (2)  mouth  gag;  (3)  tongue  forceps  (Fig.  102, 
No.  4);  (4)  two  cans  of  ether,  sealed;  (5)  three  large  safety-pins; 
(6)  six  small  towels;  (7)  a  piece  of  gutta-percha  tissue,  3  by  5 
inches;  (8)  sterile  vaseline  to  protect  the  skin  from  ether;  (9)  a 
one-ounce  bottle  of  sterile  olive  oil  or  castor  oil  for  use  in  the 
eyes  when  irritated  by  ether;  (10)  three  or  four  curved  clamps, 
such  as  the  Kelly-Pean  (Fig.  129,  No.  8);  (11)  ten  or  more  folded 
strips  of  gauze,  2  by  6  inches,  for  clearing  mouth  and  throat 
from  mucus. 

In  addition  there  will  be  provided  for  the  anaesthetist  a  hypo- 
dermic tray  containing  two  hypodermic  syringes,  sterile,  with 
the  following  preparations  and  drugs,  in  suitable  doses,  preferably 


312  THE  OPERATION 

contained  in  sterile  ampoules  ready  for  instant  use:  strychnine, 
atropine,  caffeine,  nitroglycerin,  adrenalin,  digitalin,  morphine, 
camphor  in  oil,  camphor  in  ether. 

For  the  administration  of  nitrous-oxide-oxygen  anaesthesia 
special  forms  of  apparatus  are  required,  of  which  there  are  many 
styles  on  the  market.  If  the  operating  room  is  not  provided 
with  one  of  these,  a  large  iron  flask  of  compressed  oxygen  gas 
should  be  at  hand  for  use  if  required. 

The  outfit  for  subcutaneous  infusion  of  saline  solution  should 
include:  iodine-alcohol  preparation  (equal  parts)  for  skin  steril- 
ization; a  two-litre  flask  of  sterile  normal  saline  solution,  warmed 
to  120°  F. ;  an  irrigation  stand  (Fig.  89)  with  sterile  glass  graduated 
container,  covered  with  sterile  towel ;  three  sterile  infusion  needles, 
with  sufficient  length  of  sterile  rubber  tubing  to  make  connections. 

C.  For  the  Operator  and  Assistants. — For  each  a  separate 
wash  stand  with  foot  pedals  for  the  control  of  the  running  water. 
Upon  each  stand  should  be  a  tray  containing  a  sterile  scrub 
brush,  an  orange  stick  (or  nail  file)  and  another  tray  containing 
green  soap.    A  stand  with  three  basins  containing,  respectively, 
alcohol  (50-95  per  cent.),  bichloride  of  mercury  solution  (1-1000) 
and  sterile  water.     Basin  of  bichloride  solution  with  rubber 
gloves.    Gowns.    If  the  operation  is  vaginal  or  perineal,  there 
should  also  be  a  stool  for  the  operator. 

D.  For  the  Scrubbed  Nurses. — The  same  supplies  for  scrubbing 
as  for  the  doctors,  but  in  another  room.    Also  gloves  and  gowns. 
A  table  upon  which  the  instruments  and  suture  materials  are 
to  be  arranged.    A  table  upon  which  the  sponges,  packers,  towels, 
covers,  dressings,  etc.,  are  to  be  arranged.    A  stand  with  two 
basins  containing,  respectively,  a  solution  of  bichloride  of  mercury 
(1-1000)  and  a  solution  of  salt  (0.9  per  cent.). 

E.  For  the  Unscrubbed  Nurse. — One  basin  upon  the  floor  on 
either  side  of  the  operating  table  for  used  sponges,  for  the  count 
of  which  she  is  responsible. 

Lastly,  the  sterilized  instruments  for  the  operation  are  brought 
in  and  put  upon  the  instrument  table  already  mentioned. 

The  equipment  of  the  room  having  been  enumerated,  we 
can  now  summarize  and  particularize  as  to  the  necessary  prepara- 
tion of  the  different  articles.  As  a  general  statement,  we  may 
say  that  everything  in  the  operating  room  should  be  kept  mechan- 
ically clean.  In  addition  to  this,  everything  that  will  stand 
boiling  should  receive  it  before  each  operation.  In  the  case  of 


PREPARATION  FOR  AN  OPERATION  313 

tables  and  other  large  articles  that  cannot  very  well  be  put  in  a 
sterilizer,  after  mechanical  cleansing  with  soap  and  water,  they 
should  be  thoroughly  gone  over  with  a  solution  of  bichloride 
(1-1000)  or  carbolic  (1-20).  The  walls  should  be  frequently 
gone  over  with  damp  cloths  to  prevent  the  accumulation  of  dust, 
and  at  regular  intervals  with  cloths  wet  in  an  antiseptic  solution. 
The  floor  should  be  kept  scrubbed  down  with  soap  and  water 
and  gone  over  with  an  antiseptic  solution.  At  regular  intervals 
the  room  should  be  sealed  and  fumigated  with  formalin  vapor. 
Non-absorbable  sutures  and  the  instruments  are  sterilized  by 
actual  boiling  for  at  least  ten  minutes,  as  are  the  gloves.  Absorb- 
able  suture  material  is  generally  put  up  in  sterile  containers, 
frequently  in  an  antiseptic  solution,  after  careful  sterilization 
by  heat,  chemicals  or  a  combination  of  both.  Dressings,  towels, 
sponges,  packers,  covers  and  gowns  are  sterilized  by  exposure 
to  live  steam  under  pressure  in  an  autoclave. 

II.   PREPARATION  OF  THE  NURSE 

1.  Cap. — As  the  primary  purpose  of  all  preparation  on  the 
parts  of  operator,  assistants,  and  nurses  is  the  prevention  of  the 
introduction  of  extraneous  infectious  material  into  the  wound 
or  field  of  operation,  the  procedure  naturally  divides  itself  into 
two  steps:  the  sterilization,  so  far  as  possible,  of  those  parts 
brought  into  closest  contact  with  the  patient,  and  the  covering 
of  what  is  not  sterile  with  sterilized  material.     As  the  falling 
of  hair  or  dandruff  into  the  wound,  on  the  instruments,  dressings, 
or  on  the  field  of  operation  would  be  a  source  of  constant  danger, 
caps  (either  sterile  or  freshly  washed)  are  supplied,  which  have 
a  draw-string  that  brings  them  in  snugly  to  the  head,  closely 
covering  the  hair.    This  cap  is  generally  applied  before  scrubbing. 

2.  Scrub. — The  materials  for  the  nurse's  scrub  are  the  same 
as  those  already  enumerated  for  the  doctor's.    The  nails  (which 
should  be  kept  trimmed  short)  are  carefully  cleaned  with  the 
orange  stick,  both  beneath  and  around  the  borders.    The  hands 
and  forearms  are  thoroughly  scrubbed  with  the  brush  and  green 
soap  (both  sterile)  and  water  for  five  minutes  by  the  clock.    The 
hands  and  forearms  are  then  thoroughly  gone  over  with  alcohol 
and  then  the  bichloride  solution. 

3.  Gown  and   Gloves. — The  sterile  gown  is  then  put  on, 
some  one  who  is  not  scrubbed  fastening  it  in  the  rear.    Finally, 
the  sterile  gloves  are  put  on,  the  sleeves  of  the  gown  being  tucked 


314  THE  OPERATION 

into  the  wrist  piece  of  the  gloves.  It  should  be  fully  appreciated 
that  the  wearing  of  gloves  does  not  in  the  slightest  excuse  the 
neglecting  of  full  attention  to  the  scrub.  Should  the  gloves  by 
any  chance  be  torn  or  pierced  by  a  needle  during  the  course  of 
the  operation,  unclean  hands  would  be  just  as  serious  a  jeopardy 
to  the  patient  as  though  gloves  had  never  been  worn.  The 
scrubbing  should  therefore  be  quite  as  conscientious  with  the 
use  of  gloves  as  without  them. 

III.  OPERATING-ROOM  PERSONNEL 

Having  considered  the  equipment  and  preparation  of  the 
operating  room  for  use,  as  well  as  the  methods  of  preparation 
adopted  by  the  different  individuals,  it  is  advisable  that  we  should 
review  the  personnel  of  the  operating-room  staff  and  the  duties 
pertaining  to  each  of  its  members.  In  covering  this  field,  we 
shall  endeavor  to  adhere  to  a  logical  order  of  discussion,  as  has 
been  our  effort  in  the  preceding  pages.  The  order  of  discussion 
chosen  will  be  based  upon  the  relation  of  each  individual  to  the 
patient,  rather  than  to  the  operating  room  or  to  the  hospital. 
The  patient  and  table  being  so  placed  that  the  field  of  operation 
receives  the  best  possible  light,  the  first  duties  in  regard  to  the 
patient  are  assumed  by  the  anaesthetist. 

1.  Anaesthetist. — The  importance  of  the  duties  and  the  respon- 
sibility of  this  member  of  the  operating  staff  are  becoming  so 
widely  recognized  in  all  well-conducted  hospitals  that  it  seems 
scarcely  necessary  to  emphasize  them  in  this  place.  There  does, 
however,  exist  among  some  people  an  unfortunate  attitude 
toward  this  important  position  that  would  tend  towards  its 
belittling.  The  two  individuals  immediately  responsible  for  the 
life  and  welfare  of  the  patient  are  the  surgeon  and  the  anaesthetist, 
and  the  responsibility  is  equally  divided.  Let  those  who  would 
question  this  conclusion  take  the  question  home  and  ask  them- 
selves how  much  care  they  would  take  in  selecting  their  anaes- 
thetist as  well  as  their  surgeon.  The  answer  is  foregone.  The 
anesthetist  should  be  a  specialist  in  his  particular  line  as  well 
as  the  surgeon.  Wide  experience,  sound  judgment  and  invariable 
coolness  and  decision  are  as  much  the  requirements  of  the  one 
as  of  the  other.  The  anaesthetist  should  have  the  deciding  word 
as  to  the  choice  of  the  anaesthetics, — his  special  knowledge  along 
these  lines  particularly  fitting  him  to  judge  which  would  best 
serve  the  interests  of  the  patient.  He  administers  the  chosen 


PREPARATION  FOR  AN  OPERATION  315 

anaesthetic  and  it  is  for  him  to  say  when  anaesthesia  is  sufficiently 
deep  for  the  operation  to  begin ;  what  the  condition  of  the  patient 
is  at  the  various  stages  of  the  operation;  when,  if  at  all,  the 
administration  of  stimulants  becomes  indicated;  and  when  the 
condition  of  the  patient  indicates  the  advisability  of  hastening 
the  termination  of  operative  measures.  If  stimulants  or  restora- 
tives are  indicated,  it  is  within  the  province  of  the  anaesthetist 
to  decide  upon  the  medicament  and  the  method  of  administra- 
tion, and  even  to  undertake  the  administration.  And,  in  con- 
clusion, it  may  be  of  interest  to  note  that  this  field  of  operative 
work  is  one  into  which  the  graduate  nurse  is  taking  an  increasingly 
important  part,  the  anaesthetic  work  in  some  of  our  most  impor- 
tant clinics  being  in  the  hands  of  nurses. 

2.  As  regards  the  duties  of  the  operator,  little  need  be  said, 
the  term  and  its  attendant  duties  and  responsibilities  being  well 
recognized  and  self-explanatory.     In  abdominal  operations,  he 
generally  stands  at  the  right  of  the  patient. 

3.  The  first  assistant  stands  upon  the  opposite  side  of  the 
table  from  and  facing  the  operator,  in  abdominal  work,  and  at 
his  right  side  in  vaginal,  perineal,  or  rectal  operations. 

4.  The  second  assistant  stands  on  the  same  side  of  the  table 
with  and  at  the  right  side  of  the  operator,  in  abdominal  work, 
standing  at  his  left  in  minor  operations. 

5.  The  nurse  in  charge  of  the  instruments  stands  between 
the  first  assistant  and  the  instrument  table,  in  abdominal  opera- 
tions, and  between  the  operating  and  instrument  tables  in  minor 
operations. 

6.  The  nurse  in  charge  of  sponges,  dressings,  etc.,  stands 
between  the  operating  table  and  the  dressing  table,  at  the  left 
of  the  first  assistant  and  opposite  the  second  assistant  (Fig.  117). 

7.  The    unscrubbed    ("  dirty ")    nurse    has    no    particular 
station,  but  does  not  leave  the  operating  room  except  by  the 
direction  of  the  operator  or  one  of  the  assistants. 

8.  The  orderly  should  be  without  the  operating  room  but 
within  easy  call,  so  that  there  will  be  no  delay  in  his  attendance 
if.  needed. 

This  brief  summary  of  the  personnel  of  a  properly  equipped 
general  operating  room  places  seven  persons  on  continuous 
duty  throughout  the  course  of  each  operation,  and  should,  as  a 
result,  impress  upon  each  individual  how  great  must  be  the  care 
of  each  and  every  one  of  those  concerned  to  prevent  the  slipping 


316 


THE  OPERATION 


significance,  so  jeopardize  the  success  of  the  operation.    Increase 
directly  with  the  number  of  personal  links  in  the  aseptic  chain, 
and  this  unavoidable  increase  in  the  staff  should  be  accompanied 
by  an  equal  effort  to  avoid  the  slightest  possibility  of  error, 
the  number  of  personal  links  in  the  aseptic  chain,  and  this  un- 


4ODI]Q°]  O© 


16 


FlG.  117. — Diagram  of  arrangement  of  operating  room.  1 .  Operating  table.  2.  Instru- 
ment and  dressing  table.  3.  Solution  stand  for  surgeon.  4.  Solution  stand  for  nurse. 
5.  Stool  for  anaesthetist.  6.  Table  for  anaesthetist.  7.  Irrigation  stand.  8.  Solution 
stand  for  hand  preparation.  9.  Table  for  basin  of  gloves.  10.  Surgeon.  11.  First  assist- 
ant. 12.  Second  assistant.  13.  Instrument  nurse.  14.  Sponge  and  dressing  nurse.  15 
Door  leading  into  main  hall  of  operating  suite.  16.  Door  leading  into  doctors'  scrub 
room  or  dressing  room. 

Note. — A  better  arrangement  would  be  to  have  2,  4,  13  and  14  on  the  other  side  of  the 
operating  table. 

IV.  DUTIES  OF  OPERATING-ROOM  NURSES 

In  our  discussion  of  the  operating-room  personnel,  we  included 
three  nurses  as  necessary  for  the  proper  conducting  of  the  work. 
These  should  be,  in  order  of  seniority,  the  unscrubbed  nurse,  the 
nurse  in  charge  of  instruments  and  sutures  and  the  nurse  in  charge 
of  dressings,  sponges,  etc.  In  those  smaller  hospitals  with  but 
one  operating  room,  the  graduate  nurse  in  charge  of  the  operating 
room  should  fill  the  duties  of  unscrubbed  nurse.  In  the  larger 
hospitals  with  an  operating  suite  consisting  of  several  rooms,  the 


PREPARATION  FOR  AN  OPERATION  317 

ideal  arrangement  would  be  to  have  a  graduate  in  charge  of 
each  room;  but,  should  this  be  impossible,  the  term  of  service 
in  the  operating  room  should  be  for  at  least  three  months,  the 
first  month  at  the  sponge  table,  the  second  at  the  instrument 
table  and  the  third  as  unscrubbed  nurse.  As  the  duties  of  this 
position  are  developed,  the  reasons  for  the  emphasis  placed  upon 
it  will  become  apparent. 

1.  Unscrubbed  Nurse. — The  unscrubbed  nurse  is  responsible 
for  the  final  preparation  of  the  patient  upon  the  table.  She 
catheterizes  the  patient  and  gives  the  final  scrub,  or  applies  the 
iodine  solution  where  the  iodine  preparation  is  used.  She  makes 
sure  that  the  solution  basins  for  the  surgeon  and  for  the  nurse 
are  filled  with  the  proper  solutions;  that  the  instrument  nurse 
has  all  the  necessary  instruments  and  sutures;  and  that  the  sponge 
and  dressing  nurse  has  the  proper  supplies  for  the  operation.  In 
addition  to  these  duties  is  that  one  which  involves  the  greatest 
responsibility, — the  keeping  count  of  the  sponges  used  and  making 
them  balance  with  the  number  issued,  so  that  there  can  be  no 
possibility  of  one  remaining  in  the  abdomen.  This  responsibility 
is  shared  with  her  by  the  sponge  and  supply  nurse,  but  the  final 
burden  of  whether  or  not  a  sponge  is  missing  lies  with  her.  She 
must  see  that  the  surgeon  does  not  close  the  abdomen  with  a 
sponge  remaining  therein,  unless  he  so  does  upon  his  own  re- 
sponsibility after  due  warning. 

This  nurse,  in  addition  to  her  duties  towards  operator  and 
patient,  should  bear  in  mind  the  fact  that  the  anaesthetist  may 
need  her  assistance.  She  should  be  ready  to  anticipate  his  wants 
and  to  help  him  if  called  on  in  a  sudden  emergency.  The  ordinary 
emergencies  which  the  anaesthetist  may  have  to  meet  in  the 
course  of  an  operation  are  three  in  number:  (1)  Obstructed 
breathing,  indicated  by  cyanosis  of  the  face.  This  may  be  due 
to  the  tongue  or  jaws  dropping  back,  or  to  accumulation  of  mucus 
in  the  throat.  The  remedy  is  to  lift  the  lower  jaw  up,  to  draw 
the  tongue  forward,  and  to  wipe  out  the  mouth  and  throat  with 
a  swab  of  gauze  on  a  clamp.  (2)  The  patient  may  stop  breathing, 
due  to  central  paralysis.  There  are  three  common  measures  used 
to  meet  this  emergency:  artificial  respiration,  rhythmic  traction 
of  the  tongue  and  lowering  the  patient's  head.  Artificial  respira- 
tion may  be  done  by  the  Silvester  method  (see  Chapter  XXIX) 
or  by  the  Marshal-Hall  method,  which  consists  in  compressing 
the  lower  segment  of  the  ribs  by  the  hands  placed  on  either  side. 


318  THE  OPERATION 

This  forces  the  air  out  and  the  natural  expansion  of  the  ribs  draws 
the  air  in.  It  is  not  so  efficient  as  the  Silvester  method  and  far 
less  efficient  than  the  Shafer  method,  but  the  latter  is  not  avail- 
able with  the  patient  in  the  dorsal  position  on  the  operating  table, 
Rhythmic  traction  on  the  tongue  (Laborde's  method)  consists 
in  seizing  the  tongue  with  forceps,  drawing  it  out  of  the  mouth, 
and  alternately  making  strong  traction  and  relaxation  at  the 
rate  of  about  fifteen  times  a  minute.  This  acts  as  a  powerful 
stimulant  to  the  respiration.  (3)  Shock  or  collapse  may  occur, 
particularly  towards  the  latter  part  of  a  prolonged  operation. 
Its  approach  will  be  indicated  by  pallor  of  the  face,  rapid  pulse, 
shallow  respiration  and  lowered  blood-pressure.  The  measures 
used  to  combat  this  condition  are  numerous.  The  principal  ones 
are:  (a)  a  hypodermic  injection  of  one  of  the  stimulants  contained 
in  the  hypodermic  tray;  (6)  elevation  of  the  foot  of  the  table  to 
allow  blood  to  gravitate  to  the  head;  (c)  warm  salt  solution 
sometimes  with  coffee  given  by  rectum;  (d)  infusion  of  normal 
saline  into  a  vein,  under  the  skin  of  the  breast  or  thighs,  or 
directly  into  the  abdominal  cavity  through  the  wound;  (e)  arti- 
ficial warmth;  (/)  bandaging  the  extremities  so  as  to  empty  them 
of  blood  in  order  that  the  brain  may  have  all  the  blood  that  can 
be  given  it.  Both  arms  and  both  legs  should  be  bandaged  from 
the  toes  and  fingers  to  the  trunk.  Flannel,  gauze  or  muslin 
bandages  may  be  used.  The  bandages  should  be  applied  with 
even  pressure,  but  very  firmly.  No  padding  need  be  used  under 
them. 

2.  Instrument  and  Suture  Nurse. — It  is  the  duty  of  this 
nurse  to  apply  the  sterile  covers  to  the  instrument  table  and  to 
arrange  upon  it  the  instruments  when  they  are  brought  to  her. 
She  is  to  arrange  them  in  an  orderly  manner  so  that  she  can 
have  them  promptly  as  required.     She  must  have  the  various 
suture  materials  threaded  in  suitable  lengths  and  sizes  upon 
suitable  needles  when  they  are  needed.    Finally,  as  she  becomes 
more  experienced,  she  will  find  that  anticipation  of  commands 
has  succeeded  compliance  to  them  and  that  she  has  everything 
at  the  hand  of  the  surgeon  or  the  assistant  without  the  need  of 
any  warning  that  it  will  be  required.     And  this  attainment 
marks  her  entrance  as  an  integral  part  of  what  should  be  a  perfect 
and  harmonious  machine  working  together  for  the  best  interests 
of  the  patient. 

3.  Sponge  Nurse. — This  nurse,  being  the  least  experienced 


PREPARATION  FOR  AN  OPERATION  319 

of  the  operating-room  staff,  is  given  that  position  which,  while 
in  no  way  inferior  in  importance  and  responsibility,  requires  less 
intimate  knowledge  of  the  various  steps  in  the  technic  of  the 
different  operations  at  which  she  may  attend.  In  outlining  her 
duties,  we  will  assume  that  the  precaution  (so  necessary  in  every 
well-conducted  operating  room)  of  putting  up  all  supplies  for 
operating  use  in  definite  quantities  has  been  observed.  She 
arranges  her  sterile  towels,  covers,  sponges,  packers  and  dressings 
upon  the  table  (which,  as  with  the  instrument  table,  has  a  sterile 
cover)  in  an  orderly  manner  that  will  enable  her  to  supply  the 
articles  required  with  promptitude.  She  will  open  packages  of 
sponges  only  as  required  for  use,  making  a  careful  count  of  the 
contents  of  each  package  as  opened  to  see  if  its  contents  agree 
in  number  with  the  routine.  She  will  remember  how  many  of 
each  article  she  has  issued  to  the  operator  and  convey  this  infor- 
mation to  the  unscrubbed  nurse,  upon  demand.  She  will  see 
that  all  packers  are  wrung  out  of  hot  sterile  salt  solution  before 
being  passed  to  the  operator;  that  they  have  haemostats  or  some 
other  identifying  mark  fastened  to  the  tapes;  and  will  keep  the 
same  careful  count  as  of  sponges.  The  grave  responsibility 
assumed  by  this  member  of  the  operating  staff,  although  shared 
by  others,  should  be  constantly  in  her  mind  and  prevent  any 
lapse  that  may  be  regretted  when  the  time  for  prevention  has 
passed  and  naught  but  regret  is  left. 

V.  CARE  OF  THE  ANESTHETIZED  PATIENT 

This  particular  aspect  of  the  subject  of  surgical  and  gynaeco- 
logical nursing  must,  necessarily,  begin  in  the  ward  before  the 
patient  starts  for  the  operating  room.  Steps  must  there  be  taken 
to  foreguard  the  patient  from  exposure  to  draughts  and  chilling 
on  the  way  to  the  operating  room  and  also  on  the  table  during 
the  first  stages  of  anaesthesia.  The  body  should  be  protected 
by  a  warm  gown  and  the  limbs  by  clean  Canton  flannel  or  woollen 
leggins.  The  patient  should  then  be  warmly  wrapped  in  blankets 
for  transportation  to  the  operating  room.  The  patient  should 
be  transferred  from  the  carriage  to  the  table  in  the  same  coverings 
that  she  wears  to  the  room.  All  of  the  many  forms  of  operating 
table  in  use  at  the  present  time  are  primarily  designed,  as  they 
should  be,  for  the  convenience  of  the  operator,  but  it  is  unfortu- 
nate that  in  most  cases  the  comfort  of  the  person  lying  on  the 
table  is  not  thought  worthy  of  even  secondary  consideration. 


320  THE  OPERATION 

In  the  anaesthetized  patient  all  the  muscles  are  completely  re- 
laxed, and  in  this  condition  he  is  peculiarly  liable  to  injury  from 
lying  for  a  long  time  in  a  strained  and  unnatural  position.  Two 
points  are  especially  to  be  remembered.  If  an  arm  or  a  leg  is 
allowed  to  hang  over  the  side  of  the  table  (Fig.  118),  pressure  of 
the  sharp  edge  will  inevitably  cause  a  painful  injury,  from  which 
the  patient  will  suffer  acutely  for  many  days.  If  one  of  the 
large  nerve  trunks  happens  to  lie  in  the  line  of  pressure,  paraly- 
sis of  the  muscles  supplied  by  it  will  follow  which  may  not  be 
recovered  from  for  weeks  or  months.  Pressure  from  straps  or 
upright  posts  attached  to  the  table  may  also  be  responsible  for 
injuries  of  this  kind. 


FIG.  118. — Position  for  breast  operation,  showing  improper  position  of  arm  resting  on 
edge  of  table.     Arm  should  be  held  by  nurse  to  prevent  pressure. 

The  curve  of  the  back  where  it  does  not  touch  the  table 
should  be  properly  supported  by  a  cushion  or  pillow.  Without 
this  precaution  the  relaxed  and  unconscious  patient  is  subjected 
to  severe  strain  of  the  spinal  ligaments  and  muscles,  and  this  is 
exaggerated  when,  as  in  gall-stone  operations  (Fig.  119),  a  hard 
support  is  placed  under  the  lower  ribs,  if  the  small  of  the  back 
is  not  supported  at  the  same  time.  From  this  cause  patients 
often  suffer  agonizing  backache  for  days  after  an  operation. 
The  temperature  of  the  operating  room  should  be  kept  be- 
tween 75°  and  85°  F.  to  prevent  any  danger  of  chilling.  Dur- 
ing the  progress  of  the  operation,  those  parts  of  the  patient 
that  are  not  necessarily  exposed  for  operative  purposes  are 
kept  warmly  wrapped  and  covered  in  blankets.  In  some  of 


PREPARATION  FOR  AN  OPERATION 


321 


the  hospitals,  this  desirable  end  is  additionally  sought  by 
the  use  of  a  hot-water  cushion  for  the  top  of  the  operating 
table.  The  operation  being  completed  and  the  dressings  applied, 
the  patient  is  once  more  warmly  wrapped  throughout  with  warm 
blankets  and  returned  to  her  bed.  Before  leaving  the  operating 
room,  any  wet  places  are  wiped  dry  and  any  wet  clothing  is 
removed,  to  preclude  the  possibility  of  the  patient  being  per- 
mitted to  remain  in  the  ward  in  wet  clothing. 

VI.  APPLICATION  OF  THE  FIRST  DRESSING 

Before  removing  from  the  operating  table,  the  first  dressing 
(that  will,  ordinarily,  remain  in  place  from  ten  days  to  two  weeks) 


Fia.  119. — Pillow  support  under  back  for  operation  on  gall-bladder. 

is  applied.  This  consists  of  sufficient  sterile  gauze  to  thoroughly 
cover  and  protect  the  wound  and  its  immediate  vicinity  and 
absorb  any  discharges  that  may  occur.  The  gauze  may  be 
arranged  in  pads  or  the  loose  form  described  as  fluffs  or  handker- 
chiefs. In  an  abdominal  operation  this  dressing  is  held  in  place 
by  from  two  to  four  strips  of  two-inch  adhesive  plaster,  the  number 
of  strips  depending  upon  the  length  of  the  wound.  Care  should 
be  taken  that  the  lowest  strip  of  plaster  (that  nearest  the  symphy- 
sis)  is  placed  far  enough  down  to  fully  cover  and  keep  covered  the 
lower  angle  of  the  abdominal  wound.  Where  it  is  expected  that 
frequent  redressings  will  be  necessary,  as  in  infected  cases,  instead 
of  the  solid  adhesive  strip,  small  strips  are  fastened  at  the  sides 
with  tapes  attached  to  permit  their  being  tied  across  the  dressing. 
This  dressing  being  applied,  the  patient  is  lifted  from  the  table, 
the  back  wiped  dry  and  the  patient  laid  upon  the  carriage,  the 
21 


322  THE  OPERATION 

abdominal  binder  being  already  in  place  upon  the  carriage.  The 
binder  is  then  brought  across  in  front  and  pinned  with  safety 
pins,  darts  being  made  in  the  sides  with  safety  pins  to  make  the 
binder  fit  more  snugly  and  evenly.  As  the  binder  generally 
has  a  tendency  to  slip  up,  it  is  well  to  apply  a  towel  or  strap  of 
some  kind,  running  from  the  side  of  the  binder  around  the  thigh 
in  a  loop  and  returning  to  be  fastened  at  its  starting  point.  With 
such  an  anchor  applied  on  each  side,  it  will  be  impossible  for 
the  binder  to  work  up  around  the  waist  upon  the  return  of  the 
patient  to  bed,  as  is  not  infrequently  the  case  with  the  ordinarily 
applied  binder. 

VII.  CARE  OF  THE  PATIENT  AFTER  OPERATION 

The  gown,  if  wet,  is  now  removed,  the  patient  warmly  wrapped 
in  blankets  that  have  been  kept  heated  during  the  operation 
and  returned  to  her  bed.  The  patient  should  be  accompanied 
on  the  return  trip  from  the  operating  room  to  the  ward  by  a 
physician,  as  a  precaution  against  any  sudden  emergency  arising 
on  the  trip  and  causing  trouble  for  the  lack  of  a  physician's 
presence.  When  the  patient  is  returned  to  her  bed,  she  should 
not  be  without  a  nurse  in  constant  attendance  until  she  has  fully 
reacted  from  the  anaesthetic.  While  under  the  effects  of  an 
anaesthetic,  it  would  be  a  very  simple  matter  for  the  patient  to 
draw  particles  of  vomitus  into  the  air  passages  and  become 
asphyxiated  or  set  up  an  aspiration  pneumonia,  as  the  result 
of  neglect.  It  is,  also,  not  infrequent  for  patients  to  give  the 
first  evidences  of  post-operative  shock  during  this  period,  with 
the  natural  consequence  that  neglect  of  immediate  remedial 
measures  may  lead  to  results  of  a  fatal  character.  The  nurse 
on  duty  at  the  bedside  during  this  period  should  watch  the 
patient  carefully,  keeping  an  accurate  record  of  the  pulse  and 
watching  the  general  condition.  She  should  have  a  pus  basin 
at  hand  to  receive  the  vomitus  and  see  that  the  face  is  kept 
clean  and  the  mouth  free  from  particles  of  vomitus.  The  pus 
basin  may  be  placed  at  the  side  of  the  patient's  face  and  when 
vomiting  occurs  the  patient's  head  and  shoulders  should  be  turned 
to  this  side,  by  means  of  a  hand  under  the  opposite  shoulder,  so 
that  the  vomitus  will  be  discharged  into  the  basin  and  there  will 
be  a  minimum  of  danger  from  aspiration  of  particles. 


CHAPTER  XXIV 
SELECTION  OF  INSTRUMENTS 

THE  selection  of  instruments  for  operations  (while  ordinarily 
included  in  the  duties  of  the  assistant)  not  infrequently  devolved 
upon  the  operating-room  nurse.  Owing  to  individual  preferences 
on  the  part  of  different  operators,  it  is  impossible  to  prescribe 
hard-and-fast  rules  regarding  the  instruments  used,  but  there 
are,  however,  fairly  definite  sets  used  in  certain  procedures. 
Variations  from  these,  while  numerous,  may  be  considered  as 
unimportant  and,  in  the  case  of  staff  surgeons,  easily  learned. 

1.  Dissecting  Set  (Fig.  120). — In  practically  every  cutting 
operation,  the  dissecting  set  is  the  first  employed.    This  consists 
of  one  or  more  scalpels;  two  dissecting  forceps  (one  for  operator 
and  one  for  the  assistant) ;  two  scissors  (straight  and  of  medium 
size);  half  a  dozen  small  clamps  (artery  forceps);  needles  (either 
straight  or  curved,  round  or  cutting,  according  to  the  preference 
of  the  operator) ;  needle-holders  (generally  two  where  the  opera- 
tion is  at  all  extensive);  and  sutures  and  ligatures.     In  dissec- 
tions of  somewhat  extensive   character,   retractors   should   be 
added  to  this  list. 

With  the  above  enumerated  list  of  instruments  as  a  basis, 
we  may  gradually  build  up  the  larger  groups  necessary  for  more 
extensive  operations. 

2.  General  Abdominal  Set. — This  outfit  may  be  considered 
as  a  dissecting  set,  sufficiently  augmented  (Fig.  121)  to  permit  of 
an  exploration  of  the  abdominal  cavity.    The  number  of  artery 
clamps  is  increased  to  twelve.    To  these  are  added  six  medium- 
sized,  curved  clamps.    In  addition  to  the  smaller-sized  dissecting 
forceps,  one  long  thumb  forceps  is  included  for  the  proper  placing 
of  pads  for  packing  off  the  intestines  and  for  such  other  uses  as 
may  require  intraperitoneal  manipulation.     The  retractors  are 
increased  by  the  addition  of  sets  of  two  larger  sizes  than  those 
used  in  ordinary  dissections.     The  needles  must  include  some 
fine,  round  ones  for  visceral  repair  and  the  suture  material  should 
include  (for  the  same  purpose)  fine  catgut,  fine  silk,  or  fine  linen 
thread — possibly  all  three.     This  may  be  considered  a  set  that 
will  suffice  for  an  exploratory  laparotomy,  but  that  must  be 

323 


324 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS  325 

supplemented  from  one  of  the  special  abdominal  sets,  dependent 
upon  the  condition  that  is  expected  or  may  be  revealed  during 
the  exploration. 

With  this  as  the  basis  for  abdominal  work,  we  can  proceed 
to  the  sets  formed  around  it  for  operations  upon  special  regions 
and  conditions. 

3.  Appendix  Set. — The  instruments  necessary  for  operation 
are  identical  with  those  of  the  general  abdominal  set,  with  one 
or  two  possible  additions.    There  may  be  (in  addition  to  the  two 
dissecting  forceps  already  mentioned)  one  smooth  thumb  forceps 
for  use  in  inverting  the  stump  of  the  appendix.     It  is  possible 
that  a  special  clamp  may  be  used  for  crushing  the  appendix 
before  amputation  and  an  actual  cautery  (either  Paquelin  or 
electric)  for  cauterizing  the  stump. 

4.  Gallbladder  Set  (Fig.  122).— The  gall-bladder  set,  also, 
is  identical  with  the  general  abdominal  outfit,  certain  additions 
being  necessary  for  operations  upon  this  organ.    There  should  be 
a  trocar  and  cannula,  especially  adapted  to  evacuating  the  gall- 
bladder.   There  should  be  scoops  (or  dull  curettes)  devised  for 
the  purpose  of  removing  stones  from  the  gall-bladder  and  ducts. 
A  long,  malleable  probe  for  exploration  of  the  ducts  should  alsp 
be  at  hand. 

5.  Stomach  and  Intestine  Set  (See  Fig.  101).— For  operations 
upon  the  stomach  and  intestines,  practically  the  only  additions 
to  the  general  abdominal  set  are  the  specially  devised' clamps  for 
use  in  operations  upon  the  gastro-intestinal  canal.    The  character 
of  the  operation  and  the  expressed  preference  of  the  operator 
will  decide  the  number  and  type  of  clamps  used. 

6.  Kidney  Set. — Operations  upon  the  kidney  require  little 
variation  from  the  general  abdominal  set.    The  needles  preferable 
for  kidney  suture  are  round.     In  case  of  nephrectomy,  large, 
heavy  clamps  will  be  desired  for  clamping  off  the  pedicle  before 
removing  the  kidney.    Heavy  silk  will  probably  be  subsequently 
required  for  a  ligature.     Any  of  the  usual  suture  materials,  as 
plain  or  chromic  catgut,  kangaroo  tendon,  silk,  silkworm-gut,  or 
silver  wire,  may  be  used  in  closing  this  incision  as  any  of  the 
others  in  surgical  procedures. 

7.  Pelvic  Set  (Fig.  123). — The  instruments  required  for  pelvic 
(gynaecological)  surgery  are  primarily  the  same  as  those  for  any 
general  abdominal  work,  with  such  additional  articles  as  may  be 
indicated  by  the  particular  procedure  in  view.     In  the  simpler 


326 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS  327 

operations,  such  as  those  for  displacements,  the  only  instrument 
absolutely  necessary,  beyond  the  general  abdominal  set,  is  one 
of  those  designed  for  seizing  and  elevating  the  uterus — a  double 
tenaculum,  a  volsellum,  or  a  uterine  elevating  forceps.  With 
increasing  gravity  of  the  type  of  operation,  the  variety  in  instru- 
ments is  only  along  the  line  of  the  addition  of  longer,  heavier 
scissors  and  clamps.  For  a  panhysterectomy  for  non-malignant 
condition,  two  long-handled  scissors  (one  straight  and  one 
curved  on  the  flat)  and  six  long,  heavy  clamps  (either  straight  or 
curved,  as  preferred  by  the  operator)  should  be  added.  If  the 
hysterectomy  is  on  account  of  malignancy,  two  of  Wertheim's 
right-angled  hysterectomy  clamps  should  be  added  and  the  num- 
ber of  medium-sized,  curved  clamps  increased  from  six  to  twelve. 
The  retractors  should  be  of  the  largest  size  available  for  deep 
exposure. 

8.  Hernia  Set. — The  instruments  for  a  simple  hernia  are 
identical  with  those  for  general  work.    The  larger  sized  retractors 
are,  generally,  not  needed,  as  is  also  the  case  with  the  long  abdomi- 
nal thumb  forceps.   It  is  well  to  add  a  grooved  director  and  a  blunt 
dissector,  as  these  instruments  are  required  by  some  operators. 

9.  Extensive    Dissecting  Set. — In  operations   requiring  ex- 
tensive and  careful  dissection  (such  as  those  performed  for  the 
radical  cure  of  a  malignant  growth  of  the  breast,  or  a  complete 
removal  of  the  glands  of  the  neck)  the  routine  dissecting  set,  as 
originally  outlined,  must  be  considerably  augmented.     The  set 
for  a  radical  breast  operation  has  been  described  as  "  a  dissecting 
set,  plus  all  of  the  artery  forceps  in  the  instrument  case,"  and 
this  may  be  accepted  as  fairly  accurate  and  almost  equally 
applicable  to  an  extensive  neck  dissection.     It  is  also  well,  in 
those  cases,  to  add  a  blunt  dissector. 

10.  Rectal   Set. — The   instruments   required   for  operations 
upon  the  anus  and  rectum  will  necessarily  vary  considerably 
with  the  type  of  operation  to  be  performed.    The  basis,  however, 
of  this  set  (as  of  the  others  so  far  considered)  is  the  ordinary 
dissecting  set.    For  any  operation  upon  the  interior  of  the  rectum 
or  anus  (through  the  anal  orifice),  some  type  of  rectal  speculum 
should  be  added  to  the  dissecting  set.    Beyond  this,  the  supple- 
mentary instruments  must  depend  on  the  operation  and  route 
chosen. 

A.  For  Hemorrhoids  (Fig.  124). — Where  the  operation  is  to 
be  by  clamp  and  actual  cautery,  most  of  the  instruments  of  the 


328 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS  329 

dissecting  set  are  superfluous.  Neither  knives,  scissors,  artery 
forceps  nor  sewing  materials  are  ordinarily  required,  although  it 
is  quite  customary  to  have  them  ready  in  case  of  failure  on  the 
part  of  the  cautery.  The  routine  set  would  be  a  rectal  speculum; 
two  dissecting  forceps;  six  small  hemorrhoid  forceps;  one  large 
hemorrhoid  pedicle  clamp;  and  an  actual  cautery.  If  the  opera- 
tion of  ligation  and  excision  is  chosen,  the  simple  dissecting  set 
(with  the  addition  of  a  rectal  speculum  and,  possibly,  two  or 
three  medium-sized  curved  clamps)  will  suffice.  This  same  set, 
augmented  by  an  additional  half-dozen  haemostatic  forceps,  will 
suffice  for  the  Whitehead  operation.  It  is  well  to  have  salt 
solution  irrigation  ready  for  intrarectal  operations  of  this  type. 

B.  For  Fissure  or  Fistula  in  Ano. — In  either  of  these  condi- 
tions, the  dissecting  set  need  be  augmented  only  by  the  addition 
of  a  rectal  speculum,  a  grooved  director  and  a  curved  (sharp, 
blunt,  or  probe-pointed)  bistoury. 

C.  For  Resection.- — Any  resection  of  the  lower  bowel  (by  no 
matter  what  method  or  route)  is   bound  to   adhere   more  or 
less  closely  to  the   type   described   under   extensive   dissection. 
Practically  the  same  set  of  instruments  may  be  used,  augmented 
by  a  blunt  dissector  and  (if  approached  by  the  sacral  route)  also 
by  certain  instruments  from  the  bone  sets.     These  latter  will 
probably  be  a  Gigli  saw,  periosteal  elevator  and  bone-cutting 
forceps. 

11.  Female  Perineal  Set  (Fig.  125). — For  the  repair  of  lacera- 
tions of  the  female  perineum,  the  usual  dissecting  set  is  once 
more  the  basis  of  selection.    To  it  may  be  added  six  extra  artery 
forceps,  six  medium-sized  curved  clamps  and  the  right  and  left 
Emmett   scissors   specially  designed   for  this   work.     Where   a 
special  type  of  needle  (as  the  Peaslee,  Reverdin,  Ashton,  or 
Hirst)   is  not  employed,  several  fairly  heavy,   curved  cutting 
needles  should  be  supplied  for  the  heavy,  perineal  sutures  and  a 
lighter,  full-curved  cutting  needle  for  the  intravaginal  sutures. 
The  suture   materials  most  commonly  used  are  silkworm-gut, 
chromic  gut  and  kangaroo  tendon. 

12.  Uterine  Curettage  Set  (Fig.  126).— For  curettement  of 
the  uterus,  the  following  instruments  are  necessary :  perineal 
retractor  or  vaginal  speculum;  volsellum,  or  double  tenaculum 
forceps,  or  single  tenaculum;  uterine  sound;  small  and  large 
uterine  cervical  dilators;  sharp  and  dull  uterine  curettes;  uterine 
dressing  forceps;  scissors,  and  sponge  holders. 


330 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS  331 

13.  Trachelorrhaphy  Set. — As  repair  of  the  cervix  is  generally 
preceded  by  curettage,  the  trachelorrhaphy  set  is  formed  by 
combining  the  curettage  and  dissecting  sets. 

14.  Perineal  Prostatectomy  Set. — For  perineal  prostatectomy 
by  Young's  method  a  greatly  augmented  and  supplemented 
dissecting  set  is  necessary.    The  artery  clamps  should  be  increased 
to  twelve  or  eighteen.    Six  medium-sized  curved  clamps  should 
be  added.     In  addition,  there  should  be:  throe  or  four  sizes  of 
Young's  prostatectomy  retractors;  two  sizes  of  Young's  prostatic 
lobe  forceps;  one  Young  prostatic  tractor;  one  Young  prostatic 
enucleator;  and  a  metal  urethral  sound  of  suitable  size. 

The  preceding  groups,  while  not  exhaustive,  may  be  con- 
sidered a  fairly  accurate  general  sketch  of  the  types  of  instru- 
ments selected  for  use  in  those  common  operations  upon  the  soft 
tissues  that  fall  within  the  realms  of  general  surgery  and  gynaecol- 
ogy. The  following  groups  will  apply  to  the  surgery  of  the  bony 
tissues  and  will  (in  their  turn)  make  no  pretence  of  being  the 
only  (or  necessarily  the  best)  selection  of  instruments  for  any 
particular  operation.  The  effort  will  remain  one  to  indicate  an 
adequate  selection  that  will  be  elastic  to  the  demands  of  individual 
preference  on  the  part  of  the  operator. 

15.  Cranial    Set    (Figs.    127    and    128).— The    instruments 
required  for  operations  within  the  skull  are:  (1)  those  necessary 
for  the  scalp  incision;  (2)  those  necessary  for  opening  the  skull; 
and  (3)  those  necessary  for  the  intracranial  work.    These  require- 
ments will  be  met  by  a  dissecting  set  in  which  the  artery  clamps 
are  increased  to  twelve;  an  elastic  tourniquet,  for  the  control 
of  hemorrhage;  a  cyrtometer  for  accurate  location  of  the  proper 
area;  and  the  special  bone  set.    This  latter  consists  of  a  periosteal 
elevator;  trephining  set;  Hudson  cranial  set;  rongeur  forceps; 
Gigli  saw;  chisels;  and  mallet.    The  Hudson  cranial  set  includes 
a  brace;  several  burr  drills  of  different  sizes  and  shapes;  a  fine 
dural  separator;  and  a  cranial  rongeur  forceps.    Such  instruments 
as  may  be  required  for  the  intracranial  work  vary  so  widely 
with  the  kind  of  operative  procedure  and  individual  preference 
that  it  is  impossible  to  indicate  them  in  this  place.     In  those 
operating  rooms  where  a  great  deal  of  brain  surgery  is  done,  the 
routine  of  the  operator  is  soon  mastered.    In  others,  the  operator 
should  be  asked  to  select  such  special  instruments  as  he  may 
desire. 

16.  Amputation  Set  (Fig.   129). — The  amputation  set  may 


332 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS 


333 


Fia.  130.— Joint  resection  set.  (1>  Periosteal  elevator;  (2)  chisel;  (3)  mallet;  (4)  lion- 
jawed  forceps;  (5)  tourniquet;  (6)  saw  (Satterlee's) ;  (7)  Gigli  saw;  (8)  rongeur  forceps; 
(8)  sequestrum  forceps;  (10)  haemostatic  clamps;  (11)  small  curved  Kelly  clamps. 

vary  from  the  very  meagre  outfit  necessary  for  amputation  or 
disarticulation  of  fingers  or  toes  to  the  very  extensive  selection 
necessary  for  an  amputation  in  the  upper  part  of  the  thigh,  or 
the  Berger  shoulder-girdle  amputation.  In  the  first-mentioned 
group,  a  dissecting  set  arid  a  metacarpal  saw  or  bone-cutting 
forceps  will  answer  all  requirements.  In  the  more  extensive 


334 


THE  OPERATION 


SELECTION  OF  INSTRUMENTS  335 

operations,  these  instruments  are  only  the  beginning.  The  first 
requirement  is  general  haemostasis,  which  is  attained  by  an 
Esmarch  (or  other)  tourniquet,  sometimes  supplemented  by  the 
use  of  Wyeth's  transfixing  needles.  The  dissecting  set  being 
the  basis  of  the  selection  for  work  upon  the  soft  tissues,  the  artery 
clamps  are  increased  to  eighteen  in  number  and  augmented  by 
twelve  medium-size  curved  clamps.  To  this  set,  add  one  or 
more  large  amputating  knives.  Hypodermic  syringes  and  cocaine 
solution  should  be  prepared  for  blocking  off  large  nerve  trunks 
before  severing.  For  the  bone  work,  saws  (a  Gigli  wire  saw  and 
one  of  the  butcher  type);  bone-cutting  forceps;  rongeur  forceps; 
and  lion-jawed  holding  forceps  will  be  required.  The  needles 
and  suture  materials  will  depend  upon  the  preference  of  the 
operator.  In  general,  heavy  silk  is  used  for  tying  large  vessels; 
catgut  on  full-curved  cutting  needles  of  moderate  size  for  muscular 
and  other  subcutaneous  sewing;  and  interrupted  silkworm-gut 
on  large,  medium-curved  cutting  needles  for  skin  suture. 

17.  Wiring  or  Plating  Set. — For  the  wiring  or  plating  of 
new  or  old  ununited  fractures  the  same  reinforced  dissecting 
set  (already  enumerated  for  amputation)  is  used.     To  this  are 
added  a  periosteal  elevator;  bone-cutting  and  rongeur  forceps; 
drills;   heavy  silver  wire;  bone-plates   (Lane  or  Halsted)   and 
screws;  bone  clamps,  or  lion-jawed  forceps;  and  screw-driver. 

18.  Resection  Set   (Figs.    130  and   131).— The  instruments 
necessary  for  the  resection  of  joints  are  contained  in  the  combina- 
tion of  the  amputation  and  wiring  sets. 

19.  Osteomyelitis  Set  (Fig.  132).— The  operations  for  differ- 
ent forms  of  osteomyelitis  (whether  acute  or  chronic)  practically 
always  consisting  in  a  radical  removal  of  more  or  less  extensive 
portions  of  the  bone  involved,  the  instruments  necessary  are 
included  in  the  augmented  dissecting  set  enumerated  for  amputa- 
tion and  such  bone-cutting  instruments  as  may  be  required. 
The  bone  set  for  this  purpose  will  ordinarily  consist  of  a  periosteal 
elevator;  a  mallet;  three  sizes  of  chisels;  three  sizes  of  gouges; 
three  sizes  of  curettes;  and  two  or  three  sizes  of  rongeur  forceps. 


CHAPTER  XXV 
OPERATIVE  STEPS 

PRACTICALLY  every  operator  of  large  experience  has  a  fairly 
definite  and  exact  method  of  approaching  each  operation.  The 
details  may  vary,  but  the  succeeding  order  of  the  steps  is  almost 
invariable.  In  order  to  be  a  really  intelligent  assistant,  the  nurse 
passing  instruments  must,  in  the  first  place,  be  familiar  with  the 
general  outline  of  the  operative  technic  for  the  different  regions 
and,  after  that,  with  the  order  in  which  each  surgeon  requires 
the  instruments  for  the  next  step.  It  is  not  intended  to  convey 
the  idea  that  the  nurse  must  know  what  ought  to  be  done  and 
how  to  do  it,  but  rather  what  the  operator  is  going  to  do  and 
with  what  instruments  he  will  do  it. 

With  certain  general  regions,  the  initial  steps  of  the  various 
operations  are  practically  identical,  so  far  as  the  nurse's  duties  are 
concerned.  The  immediate  location  of  the  disease  condition  (as 
well  as  its  character)  may  vary  considerably — thus  affecting  the 
site  and  character  of  the  operative  work.  But  this  does  not, 
ordinarily,  call  for  any  change  in  the  instruments.  For  example, 
practically  every  abdominal  operation  (whether  upon  the  gall- 
bladder or  stomach,  vermiform  appendix  or  sigmoid  flexure) 
will  be  inaugurated  with  the  opening  of  the  abdomen  and  the 
exposure  of  the  contents  of  the  field  of  operation.  For  this 
purpose,  the  operator  will  need  a  scalpel  and  toothed  dissecting 
forceps,  artery  forceps,  sponges,  scissors  and  retractors.  There 
should  be  added  an  additional  dissecting  forceps  for  the  assistant. 

In  taking  up  the  subject  of  operative  steps,  an  effort  will 
be  made  to  present  a  number  of  the  more  general  and  important 
operations  of  general  surgery  and  gynaecology,  step  by  step, 
with  an  enumeration  of  the  instruments  that  will  be  needed  by 
the  operator  for  each  step.  The  operations  will  be  considered 
in  three  general  classes  (operations  upon  the  head;  operations 
upon  the  trunk;  and  operations  upon  the  extremities)  and  one 
or  more  operations  considered,  in  detail,  under  each  class. 
336 


OPERATIVE  STEPS  337 

I.  OPERATIONS  UPON  THE  HEAD 
Under  this  class,  only  one  operation  will  be  considered. 

A.  Trephining,  or  Craniotomy,  for  Intracranial  Hemorrhage: 

STEP  1. — Localization  of  area. 

Required  instrument:  cyrtometer. 
STEP  2. — Skin  incision. 

Required  instruments:    scalpel;    two  tissue  forceps; 
six  fairly  heavy  artery  forceps;  and  gauze  sponges, 
two  at  a  time. 
STEP  3. — General  ruemostasis. 

Required  instrument:  elastic  cranial  tourniquet. 
STEP  4. — Freeing  of  skin  and  periosteal  flap. 

Required  instrument:  periosteal  elevator. 
STEP  5. — Cranial  resection. 

Required   instruments:    trephines,  or    Hudson's  cra- 
nial set;  Hay's  saw,  orGigli  saw;  rongeur  forceps; 
and  dural  separator. 
STEP  6. — -Intracranial  haemostasis. 

Required  instruments:  small  gauze  sponges,  one  at  a 
time;  four  small  artery  clamps;  free,  fine  catgut 
(or  silk)  for  ligature;  fine  catgut  (or  silk)  on  fine, 
curved,  round  needle  for  ligating  suture,  in  case 
free  ligature  is  not  used;  a  needle-holder;  and 
suture  scissors. 
STEP  7. — Closure  of  incision. 

Required  instruments:  four  fairly  heavy,  curved 
cutting  needles,  threaded  with  silk  or  silkworm-gut; 
two  needle-holders;  two  tissue  forceps;  and  suture 
scissors. 

A  variation  in  this  method  of  closure  is  that  advocated  by 
Dr.  Gushing,  where  a  number  of  straight,  round  needles  (threaded 
with  silk  or  linen)  are  used  to  transfix  and  approximate  the  wound 
edges.  After  proper  approximation  and  haemostasis  have  been 
thus  accomplished,  the  sutures  are  drawn  through,  one  at  a  time, 
and  tied.  When  this  method  is  used,  a  dozen  needles  (or  more, 
should  the  length  of  the  incision  require  them)  should  be  threaded 
in  readiness. 

II.  OPERATIONS  UPON  THE  TRUNK 

Under  this  branch  of  operative  work,  a  number  of  operations 
will  be  selected  that  are  typical  of  procedures  in  the  different 
regions.  It  is  not  possible,  of  course,  to  describe,  in  detail, 
every  operation  that  can  be  performed  upon  the  trunk.  It  is 
hoped,  however,  that  those  described  will  give  a  sufficiently 
accurate  general  idea  of  the  procedure  to  enable  the  nurse  to 
readily  grasp  the  details  of  these  and  other  related  operative 
procedures. 
22 


338  THE  OPERATION 

A.  Resection  of  Portion  of  Rib  for  Empyema  (Thoracotomy) : 

STEP  1. — Incision. 

Required    instruments:     two    scalpels;     two    tissue 
forceps;  six  artery  clamps;  small  sponges,  two  at  a 
time  as  required;  and  small  skin  retractors. 
STEP  2. — Separation  of  periosteum. 

Required   instruments:    scalpel;    two  tissue  forceps; 
two  small  periostea!  elevators;  and  two  medium 
curved  clamps,  or  tissue-holding  clamps. 
STEP  3. — Resection  of  rib. 

Required   instruments:    bone-cutting   forceps;    Cigli 
wire  saw  and  handles;  director  or  carrier  for  Gigli 
saw. 
STEP  4. — Incision  of  pleura. 

Required  instruments:    scalpel;    two  tissue  forceps; 
Mayo  scissors;   and  two  tissue-holding  clamps  for 
grasping  edges  of  pleural  incision. 
STEP  5. — Institution  of  drainage. 

Required   instruments:  single,  or  double,  fenestrated 
rubber   tube;   safety   pin   for   transfixing   tube,    or 
silkworm-gut,  threaded  on   curved  cutting   needle, 
for  attaching  tube  to  edge  of  skin  incision. 
STEP  6. — Closure  of  skin  incision. 

Required  instruments:  two  medium-curved  cutting 
needles,  threaded  with  silkworm-gut;  two  needle- 
holders;  one  tissue  forceps;  and  one  suture  scissors. 

B.  Operation  for  Stones  in  the  Gall=bladder  (Cholecystotomy,  where 

the  gall-bladder  is  incised  and  drained;  Cholecystectomy,  where 
the  gall  bladder  is  removed;  Cysticotomy,  Hepaticotomy,  and 
Choledochotomy,  where  the  cystic,  hepatic,  or  common  bile-duct 
is  incised) : 
STEP  1. — Abdominal  incision. 

Required    instruments:     two    scalpels;     two    thumb 
forceps;  six  artery  clamps;  sponges;  straight,  blunt- 
pointed  scissors;  and  two  tissue-holding  clamps  for 
grasping  cut  peritoneum. 
STEP  2. — Retraction  of  abdominal  walls. 

Required    instruments:    two  medium   and  two  deep 

abdominal  retractors. 
STEP  3. — Exposure  of  field  and  protection  of  general  abdominal 

cavity. 

Required  instruments:  long  thumb  forceps  (or  long 
curved  clamps);  six  long  abdominal  packers,  wrung 
out  of  salt  solution  and  with  artery  clamps  fastened 
to  ends  of  tapes;  and  six  medium  abdominal  packers, 
similarly  treated. 

This  step  is  common  to  practically  all  intra-abdominal  opera- 
tive procedures,  the  variation  being  in  the  sizes  of  the  packers. 

STEP  4. — Incision  and  drainage  of  gall-bladder. 

Required  instruments:  two  round,  curved  needles, 
threaded  with  medium  silk,  for  stay  sutures;  two 
artery  forceps  to  carry  needles;  one  mouse-toothed 
thumb  forceps;  one  straight  scissors;  and  one  gall- 
bladder trocar  and  cannula;  gall-bladder  spoon. 


OPERATIVE  STEPS  339 

STEP  5. — Removal  of  stones. 

Required  instruments:  short,  medium  and  long 
gall-stone  scoops;  short,  medium  and  long  gall- 
stone scoop  forceps;  and  long  probe  for  searching 
ducts. 

STEP  6. — Drainage  of  gall-bladder. 

Required  instruments:  two  curved,  round  needles, 
threaded  with  No.  2  catgut;  two  needle-holders; 
one  rubber  tube,  about  eighteen  inches  long  and 
one-fourth  to  one- third  of  an  inch  internal  diameter; 
one  toothed  dissecting  forceps;  and  one  suture 
scissors. 

STEP  7. — Closure  of  abdominal  incision. 

Required  instruments:  two  toothed  dissecting  for- 
ceps; two  curved  cutting  needlas,  threaded  with 
No.  2  catgut;  four  large,  medium-curved  cutting 
needles,  threaded  with  silkworm-gut;  two  curved 
cutting  needles,  threaded  with  No.  2  chromicized 
catgut  or  kangaroo  tendon;  and  one  suture  scissors. 
C.  Removal  of  Vermiform  Appendix.  (Appendectomy) : 

STEP  1. — Abdominal  incision. 

Required  instruments:  same  as  for  gall-bladder 
incision,  with  addition  of  small  skin  retractors  and 
small  abdominal  retractors. 

STEP  2. — Retraction  of  abdominal  wall. 

Required  instruments:  same  as  for  gall-bladder 
operation. 

STEP  3. — Exposure  of  field  and  protection  of  general  abdominal 

cavity. 

Required  instruments:  same  as  for  gall-bladder 
operation,  packers  being  medium  and  small  size, 
instead  of  large  and  medium. 

STEP  4. — Delivery  of  appendix. 

Required  instruments:  two  toothed  tissue  forceps; 
one  blunt  dissector;  two  medium-sized,  curved 
clamps;  and  one  medium-sized,  straight,  blunt- 
pointed  scissors. 

STEP  5. — Removal  of  appendix. 

Required  instruments:  Cleaveland  carrier,  aneurism 
needle,  or  sharp-pointed  artery  clamp,  for  piercing 
meso-appendix;  free,  No.  2  catgut;  scissors;  scalpel: 
two  cotton-wrapped  applicators,  one  saturated 
with  carbolic  acid  and  the  other  with  alcohol  (or 
an  actual  cautery) ;  and  two  medium  heavy  clamps. 

STEP  6. — Inversion  of  appendix  stump  and  closure  of  ca-cal  wound. 
Required  instruments:  two  round  intestinal  needles 
(either  straight  or  curved),  one  threaded  with  fine 
silk  or  linen  thread,  and  the  other  with  fine  (No.  00 
or  No.  0)  catgut;  two  artery  clamps  for  use  aa 
needle-holders;  two  toothed  tissue  forceps;  one 
smooth  dissecting  forceps,  for  inverting  stump;  and 
one  suture  scissors. 

STEP  7. — Closure  of  abdominal  incision. 

Required  instruments:  same  as  in  gall-bladder  opera- 
tion, with  addition  of  small  abdominal  and  small 
skin  retractors. 


340  THE  OPERATION 

D.  Operation  for  Radical  Cure  of  Inguinal  Hernia: 

STEP  1. — Skin  incision. 

Required     instruments:      same    as    for    abdominal 
incision  in  preceding  operations,  omitting  abdominal 
retractors. 
STEP  2. — Opening  inguinal  canal. 

Required    instruments:    grooved    director;    scalpel; 
straight,     blunt-pointed     scissors;     two      toothed 
thumb  forceps;  and  two  tissue-holding  forceps. 
STEP  3. — Opening  of  hernia  sac. 

Required  instruments:  same  as  for  Step  2. 

STEP  4. — Attempted  resuscitation  of  strangulated  intestine  (when 
present). 

Required     articles:     six    large    abdominal    packers, 
wrung  out   of  hot   salt   solution,    or  two    towels, 
similarly  treated. 
STEP  5. — Intestinal  resection  (when  necessary). 

Required  instruments :  six  medium-sized  gauze  packers 
(or  fluffs)  wrung  out  of  hot  salt  solution;  four  intes- 
tinal clamps,  with  rubber-covered  blades;  two 
curved,  round  needles,  threaded  with  No.  2  catgut, 
for  controlling  mesenteric  hemorrhage;  scalpel; 
eight  artery  forceps;  four  round  needles  (straight 
or  curved),  threaded  with  fine  silk  or  linen  thread; 
two  round  needles,  threaded  with  fine  catgut 
(No.  00  or  No.  0) ;  one  smooth  and  two  toothed 
thumb  forceps;  two  needle-holders;  and  one  suture 
scissors;  small  sponges,  as  required,  two  at  a  time. 
STEP  6. — Repair  of  inguinal  rings  and  canal. 

,  Required  instruments:  two  toothed  thumb  forceps; 
two  needle-holders;  one  curved,  round  needle, 
threaded  with  fine  silk;  four  curved  needles  (cutting 
or  round),  threaded  with  kangaroo  tendon,  No.  2 
chromicized  catgut,  or  silk;  skin  retractors;  and 
one  suture  scissors. 
STEP  7. — Closing  of  skin  incision. 

Required  instruments:  two  toothed  thumb  forceps; 
two  needle-holders;  four  curved  cutting  needles, 
threaded  with  silkworm-gut;  one  curved  cutting 
needle,  threaded  with  No.  2  catgut;  and  one  suture 
scissors. 

In  this  closure,  the  silkworm-gut  may  be  omitted  and  catgut 
alone  used;  or  silk  alone  may  be  used;  or  a  subcuticular  suture 
of  silver  wire  may  be  preferred. 

This  step  may  be  preceded  by  the  placing  of  a  rubber  tube, 
rubber  tissue,  or  cigarette  drain. 

E.  Shortening  of  Round  Ligaments,  for  Retrodisplacement  of  Uterus 

(Baldy- Webster  or  Gilliam  Operation) : 
STEPS  1  and  2. — Same  as  for  gall-bladder  operation. 

Required  instruments:  same  as  for  gall-bladder 
operation. 


OPERATIVE  STEPS  341 

STEP  3. — Elevation  and  control  of  uterus. 

Required    instrument:    one  uterine  elevating  forceps, 
or  one  volsellum  forceps,  or  one  double  tenaculum 
forceps. 
STEP  4. — Operation  upon  round  ligaments. 

Required  instruments:  one  toothed  thumb  forceps;  one 
Cleaveland  carrier,  or  sharp-pointed  artery  clamp, 
for  piercing  broad  ligament  and  seizing  round  liga- 
ment; two  tissue-holding  forceps  for  holding  and 
controlling  round  ligaments;  two  curved,  medium- 
sized,  round  needles,  threaded  with  silk  or  linen 
thread;  two  needle-holders;  and  one  suture  scissors. 
STEP  5. — Closing  of  abdominal  wound. 

Required     instruments:     same,  as    for    gall-bladder 

operation. 
F.  Supravaginal  Removal  of  Uterus  and  Appendages  (subtotal  panhys 

terectomy) : 
STEPS  1,  2  and  3. — Same  as  for  round  ligament  operation. 

Required    instruments:    same  as  for  round  ligament 

operation. 
STEP  4. — Freeing  of  bladder. 

Required   instruments:    one  toothed  thumb  forceps; 
two  tissue-holding  forceps;    one  scalpel;  and  one 
medium-sized,  blunt-pointed  scissors. 
STEP  5. — Temporary  control  of  hemorrhage  and  section  of  broad 

ligaments. 

Required    instruments:   one  toothed  thumb  forceps; 
six  large,  straight,  toothed  clamps  (Ochsner  clamp) ; 
six  medium-sized,  curved  clamps;    and    one   long, 
curved,  blunt-pointed  scissors. 
STEP  6. — Section  of  uterus  and  seizure  of  cervical  stump. 

Required    instruments:    one  toothed  thumb  forceps; 
one  scalpel;  one  long,  curved,  blunt-pointed  scissors; 
and  one  volsellum  forceps. 
STEP  7. — Permanent  control  of  hemorrhage  and  closure  of  cervical 

stump. 

Required  instruments:  one  toothed  thumb  forceps; 
six  medium-sized,  curved  cutting  needles,  threaded 
with  No.  2  catgut  (double);  two  such  needles 
threaded  with  No.  2  catgut  (single);  two  needle- 
holders;  and  one  suture  scissors. 
STEP  8. — Closing  abdominal  wound. 

Required    instruments:   same  as  for  round  ligament 

operations. 
MINOR   GYNAECOLOGICAL   OPERATION.      DILATATION   AND   CURETTAGE    OP 

UTERUS;  REPAIR  OF  LACERATED  CERVIX  AND  PERINEUM 
A.  Dilatation  and  Curettage  of  Uterus: 

STEP  1. — Exposure  and  seizure  of  cervix. 

Required    instruments:   one  perineal  retractor,   with 

weight;  and  one  volsellum  forceps. 
STEP  2. — Exploration  of  uterine  canal. 

Required  instrument:  one  uterine  sound. 
STEP  3. — Dilatation  of  cervical  canal. 

Required   instruments:    one   small    cervical    dilator; 
and  one  large  cervical  dilator  (Goodell's). 


342  THE  OPERATION 

STEP  4. — Curettage. 

Required  instruments:  one  medium-sized,  sharp 
uterine  curette;  one  small,  sharp,  uterine  curette; 
one  uterine  dressing  forceps  and  narrow  strip  gauze 
for  removal  of  small  particles  from  uterus;  and  one 
heavy  scissors,  for  cutting  strip  gauze. 

B.  Repair  of  Lacerated  Cervix  (Trachelorrhaphy) : 

STEP  1. — Placing  of  stay  sutures. 

Required    instruments:   one  toothed  thumb  forceps; 
two  medium-sized,  curved  cutting  needles,  threaded 
with  silkworm-gut:    two  needle-holders;    and  two 
artery  forceps  for  clamping  ends  of  stay  sutures. 
STEP  2.— Denudation  of  cervical  scar. 

Required    instruments:    one  toothed  thumb  forceps; 

and  one  scalpel. 
STEP  3. — Suture  of  cervix. 

Required  instruments:  four  medium-sized,  curved 
cutting  needles,  threaded  with  kangaroo  tendon  or 
No.  2  cnromicized  catgut;  one  toothed  thumb  for- 
ceps; two  needle-holders;  four  artery  clamps;  and 
one  suture  scissors. 

C.  Repair  of  Lacerated  Perineum  (Perineorrhaphy) : 

STEP  1. — Placing  of  stay  sutures. 

Required   instruments:    one  toothed  thumb  forceps; 
three  medium-sized,  curved  cutting  needles,  threaded 
with  silkworm-gut;    two  needle- holders;  and  three 
artery  clamps  for  clamping  stay  sutures. 
STEP  2. — Outlining  and  denudation  of  area  of  laceration. 

Required   instruments:    two  toothed  thumb  forceps; 
one  scalpel;  two   Emmet    scissors  (right  and  left); 
and  six  artery  clamps. 
STEP  3. — Suture  of  angles. 

Required    instruments:    four    medium-sized,    curved 
cutting  needles,  threaded  with  No.  2  chromicized 
catgut;    one  toothed  thumb  forceps;    two  needle- 
holders;  four  artery  clamps;  and  one  suture  scissors. 
STEP  4. — Suture  of  perineum,  proper. 

Required    instruments:    four    large,   curved    cutting 
needles,  threaded  with  silkworm-gut;    two  needle- 
holders;    one  toothed  thumb  forceps;    four  artery 
clamps;  and  one  suture  scissors. 
STEP.  5. — Skin  approximation. 

Required  instruments:  one  toothed  thumb  forceps;  one 
medium-sized,  curved  cutting  needle,  threaded  with 
No.  2  plain  catgut;  one  needle-holder;  and  one 
suture  scissors. 

III.  OPERATIONS  UPON  THE  EXTREMITIES 
A.  Amputation  Through  the  Thigh: 

STEP  1. — Preliminary.    Application  of  the  tourniquet. 

Required  instruments:  one  rubber  elastic  band 
tourniquet  or  a  piece  of  large  rubber  tubing,  suf- 
ficiently long  to  encircle  the  limb  several  times; 
with  this,  should  be  furnished  a  towel,  folded  length- 
-  wise  in  four  thicknesses,  and  long  enough  to  encircle 
limb  under  tourniquet. 


OPERATIVE  STEPS  343 

STEP  2. — Outlining  and  dissecting  the  flaps. 

Required     instruments:     one    scalpel;     one    mouse- 
toothed  forceps;  one  scissors;  and  six  artery  clamps. 
STEP  3. — Partial  division  of  muscles  and  exposure  of  sciatic  nerve. 
Required    instruments:    one  amputation  knife;    one 
scalpel;  one  toothed  thumb  forceps;  and  one  blunt 
hook. 
STEP  4. — Cocainization  of  sciatic  nerve. 

Required     instruments:     hypodermic    syringe,    filled 

with  1  per  cent,  solution  of  cocaine. 
STEP  5. — Further  division  of  soft  parts,  down  to  bone.      , 

Required  instrument:  one  amputating  knife,   or  one 

scalpel. 
STEP  6. — Division  of  the  bone. 

Required  instruments:     one  periosteal  elevator;  one 
wide  muslin  retractor,  for  muscles  of  stump;  one 
bone  saw;  and  one  rongeur  forceps. 
STEP  7. — Securing  and  ligating  blood-vessels. 

Required    instruments:    one  dozen   (or  more)   artery 
clamps — straight  and  curved;  one  toothed  thumb  for- 
ceps;  heavy  silk,   or  linen,   ligatures;   and   catgut 
(No.  1  or  No.  2)  ligatures. 
STEP  8. — Suturing  the  muscles. 

Required    instruments:    two    large,    curved   needles, 
threaded  with  No.  2  catgut;  two  needle-holders; 
toothed  thumb  forceps;  and  one  suture  scissors. 
STEP  9. — Closure  of  skin. 

Required  instruments:  three  (or  more)  large,  curved 
cutting  needles,  threaded  with  silkworm-gut;  addi- 
tional silk  worm-gut;  two  needle-holders;  one  toothed 
thumb  forceps;  twelve  clamps  for  temporary  secur- 
ing of    ends  of    sutures;   three  cigarette  or  small 
dressed- tube  drains;  and  one  suture  scissors. 
The   instruments   and    sutures   for    this    step    must, 
necessarily,  vary  widely  with  the  individual  prefer- 
ences of  different  surgeons. 
Disarticulation  at  the  Shoulder: 
STEP  1. — Incision  of  skin  and  muscles. 

Required  instruments:  one  scalpel;  two  toothed  dis- 
secting forceps;  one  scissors;  two  skin  retractors; 
and  artery  clamps  as  required,  at  least  two  being 
constantly  at  hand. 
STEP  2. — Incision   of    capsule   of   joint   and   division   of  muscle 

attachments. 
Required  instruments:  the  same  as  for  Step  1,  with 

addition  of  periosteal  elevator. 
STEP  3. — Ligation  of  main  vessels. 

Required  instruments:  same  as  for  Step  1,  with  addi- 
tion of  blunt  dissector;   and   an  aneurism  needle 
threaded  with  strong  silk,  or  linen  ligature. 
STEP  4. — Cocainization  of  main  nerve  trunks. 

Required  instruments:  same  as  for  Step  1,  with  addi- 
tion of  one  blunt  dissector;  one  blunt  hook;  and  a 
hypodermic  syringe  filled  with  1  per  cent,  cocaine 
solution. 


344  THE  OPERATION 

STEP  5. — Division  of  remaining  tissue. 

Required    instruments:    one    amputating    knife,    or 

scalpel,  and  one  toothed  dissecting  forceps. 
STEP  6. — Securing  and  ligating  blood-vessels. 

Required     instruments:       about     a     dozen     clamps, 
straight    and    curved;    and    silk,    linen,    or    catgut 
ligatures — as  called  for. 
STEP  7. — Suturing  the  muscles. 

Required    instruments:    two   (or  more)  large  curved 
needles,  threaded  with  No.  2  catgut;  two  needle- 
holders;  one  toothed  thumb  forceps;  and  one  suture 
scissors. 
STEP  8. — Closing  the  skin  wound. 

Required    instruments:    the  same  as  for    the  corre- 
sponding step  in  the  thigh  amputation. 


CHAPTER  XXVI 
OPERATIONS  IN  PRIVATE  HOUSES 

IT  must  be  assumed,  at  the  outset,  that  no  hard-and-fast 
rules  can  be  laid  down  for  the  preparation  for  and  conduct  of 
operations  performed  in  private  houses.  The  means  and  sur- 
roundings of  the  patient  will  be  variable,  as  will  the  outfit  and 
preparedness  of  the  surgeon  to  cope  with  such  occasions.  Our 
effort  must,  therefore,  be  to  lay  down  general  principles  that 
are  to  be  observed  so  far  as  opportunity  and  the  surroundings 
permit,  and  to  indicate  a  few  of  those  measures  and  makeshifts 
that  are  of  use  in  the  absence  of  a  properly-equipped  operating 
room. 

1 .  The  Room. — A  large,  well-lighted  room  should  be  selected. 
Where  attainable  (if  the  operation  is  to  be  by  daylight),  a  room 
with  a  northern  exposure  is  preferable,  as  this  gives  an  even  light 
throughout  the  day  and  any  of  the  other  exposures  is  under  the 
direct  glare  of  the  sun  at  some  hour  of  the  day.    All  hangings, 
draperies,  pictures,  rugs,  etc.,  should  be  removed  the  day  before 
the  operation;  the  walls  and  floors  carefully  cleansed  (preferably 
being  gone  over  with  a  cloth  moistened  in  some  antiseptic  solu- 
tion, either  bichloride  1-1000  or  carbolic  acid  1-100  or  1-20); 
and  any  superfluous  articles  of  furniture  either  removed  or  so 
disposed  of  as  to  be  out  of  the  way  at  the  time  of  the  operation. 

2.  The  Table. — It  may  be  accepted,  as  a  general  thing,  that 
some  portable  form  of  operating  table  will  be  brought  by  the 
surgeon.    Should  this,  however,  not  be  the  case,  an  ordinary 
kitchen   table    may   be    pressed   into   service — being    carefully 
scrubbed  until  mechanically  clean   and   then   treated    by  the 
application  of  an  antiseptic  solution,   in  the  hope  of  further 
promoting  asepsis.    The  top  of  the  table  may  then  be  covered 
with  new  oil-cloth  or  rubber  sheeting,  which  is,  in  turn,  subjected 
to  the  antiseptic  wash. 

3.  Utensils  and  Supplementary  Supplies. — In  addition  to  the 
table  used  for  the  operation,  there  must  be  another  table  (or 
tables)  sufficiently  large  to  permit  the  proper  laying  out  in  an 
orderly  manner  of  the  various  instruments,  dressings  and  ma- 
terials used  in  the  course  of  the  operation.    These  tables  should 

345 


346  THE  OPERATION 

be  cleansed  and  covered  in  a  manner  similar  to  that  described 
for  the  operating  table.  The  instruments  and  sterile  dressings 
will  be  supplied  by  the  operator.  Certain  utensils  and  supplies 
should,  however,  be  on  hand  and  prepared  for  use  before  and 
during  the  operation.  Sufficient  linoleum,  rubber  sheeting,  oil- 
cloth, or  (in  case  of  necessity)  newspapers  should  be  at  hand  to 
cover  and  protect  the  floor  in  the  immediate  vicinity  of  the  oper- 
ating table.  There  should  be  a  chair  for  the  anaesthetist  and 
(where  urethral,  vulvar,  vaginal,  perineal  or  rectal  work  is  to  be 
done)  also  one  for  the  operator.  There  should  be  three  clean 
basins  (which  have  been  rinsed  thoroughly  with  a  strong  anti- 
septic solution)  and  an  ample  supply  of  warm  sterile  water  for 
the  proper  scrubbing  of  the  hands  and  forearms  of  the  operator, 
his  assistant  and  the  nurse.  There  should  be  green  soap,  a 
sterile  scrub  brush  and  a  sterile  orange  stick  for  each  of  these 
persons.  There  should  be  two  receptacles,  one  on  each  side  of 
the  table,  for  the  reception  of  soiled  sponges.  In  addition  to  the 
articles  already  enumerated,  at  least  four  other  basins  will  be 
required:  one  each  for  alcohol  and  bichloride  solution  for  use  in 
preparation  of  the  hands  and  arms  of  the  operating  staff;  and 
one  each  for  bichloride  solution  and  hot  salt  solution  to  be  used 
during  the  operation.  These  basins  should  be  sterilized  by 
boiling  in  a  wash  boiler,  or  by  thorough  immersion  in  an  anti- 
septic solution.  It  is  quite  possible  that,  in  some  cases  where 
the  surgeon  is  unusually  well  prepared  for  operating  under  such 
conditions,  a  number  of  the  above-mentioned  articles  may  be 
dispensed  with.  But  it  is  equally  true  that,  in  operations  of 
emergency  or  where  the  most  complete  equipment  is  for  any 
cause  lacking,  the  necessity  of  various  makeshifts  may  arise. 

4.  Artificial  Light. — When,  for  any  reason  of  urgency,  the 
operation  must  be  performed  by  artificial  light,  complications 
may  arise  that  require  great  ingenuity  for  their  subjection  or 
that  even  render  the  question  of  operation  absolutely  impossible. 
It  can  well  be  seen  that  it  would  be  almost,  if  not  quite,  out  of 
the  question  to  perform  a  delicate  abdominal  operation  in  a 
country  house  by  the  light  of  kerosene  lamps.  And  the  same 
might  well  be  the  case  in  many  gas-lighted  city  houses.  It  is 
quite  possible  that,  in  a  case  where  immediate  operative  pro- 
cedure is  imperative  and  transportation  to  a  properly-equipped 
operating  room  out  of  the  question,  the  use  of  a  kerosene  reflector 
or  bicycle  lamp,  an  acetylene  bicycle  lamp,  or  even  an  auto- 


OPERATIONS  IN  PRIVATE  HOUSES  347 

mobile  searchlight  might  be  possible.  Where  electricity  is  at 
hand,  the  problem  is  greatly  simplified.  Extension  sockets  are 
common;  reflectors  easily  obtained;  and  powerful  lights  readily 
accessible. 

5.  Substitutes  for  Lithotomy  Posts. — This  subject  has  been 
fully  considered  in  the  chapter  upon  " Postures,"  the  adjustable 
post,  the  sling  and  the  two  applications  of  the  sheet  as  substitute 
for  either  being  there  referred  to  and  described. 

6.  Kelly  Pad. — The  Kelly  pad  is  here  made  the  subject  of 
particular  remark  because  it  has  become  to  be  almost  universally 
considered  a  necessity  in  a  large  class  of  operative  work  and 
because,  at  the  same  time,  it  seems  to  be  the  most  usual  article 
to  forget  until  needed.     If  a  surgeon,  in  assembling  his  supplies 
for  an  operation,  forgets  anything,  it  is  the  Kelly  pad.     And 
most  people  would  certainly  not  consider  the  lithotomy  position 
complete  without  a  Kelly  pad  under  the  hips.     Fortunately, 
however,  there  are  very  few  of  the  different  articles  of  equipment 
so  readily  and  easily  replaced  by  the  aid  of  a  little  ingenuity. 
A  most  acceptable  substitute  is  made  by  rolling  one  (or  two) 
bath  towels  lengthwise;  curving  them  to  the  horseshoe  shape; 
and  covering  them  with  rubber  sheeting  or  oil  cloth.     A  news- 
paper roll  may  take  the  place  of  the  bath  towel.     In  fact,  a 
newspaper,  home-made  Kelly  pad  may  be  manufactured  in  a 
very  few  minutes  and  makes  a  very  acceptable  substitute.   And 
very  few  homes  are  without  newspapers. 

7.  Anaesthetic. — The  choice  of  the  anaesthetic  to  be  used 
does  not  come  under  the  duties  or  within  the  province  of  the 
nurse,  but  it  is  necessary  that  she  should  appreciate  the  dangers 
attending  the  use  of  ether  in  the  vicinity  of  a  free  flame.    This 
anaesthetic  is  more  volatile  than  chloroform  and  highly  inflam- 
mable and  explosive.     It,  therefore,  follows  that  unusual  care 
must  be  exercised  in  its  administration  where  any  exterior  cause 
for  combustion  exists.     This  caution  is  necessary,  not  only  as 
regards  gas-lights,  oil  lamps,  etc.,  but  extends  to  the  use  or 
presence  of  an  actual   cautery  within  close  proximity  to  the 
anaesthetist. 

8.  Sterilization    of    Instruments,    Water,    Etc. — It   may  be 
accepted  as  the  general  rule  for  all  operators,  where  the  work  is 
to  be  done  in  a  private  house,  to  sterilize  their  own  instruments 
and  bring  them  to  the  scene  of  operation  in  sterile  containers. 
There  are,  however,  exceptions  to  this  rule  and,  at  such  times, 


348  THE  OPERATION 

the  nurse  must  be  prepared  to  accomplish  this  necessary  pro- 
cedure with  the  means  at  her  command.  The  actual  steriliza- 
tion must,  of  course,  be  done  by  boiling,  an  ordinary  wash  boiler 
(preferably  of  small  size)  serving  very  well  for  the  purpose.  Some 
surgeons  carry  trays  that  are  used  for  the  combined  purpose 
of  instrument  tray  and  sterilizer.  In  such  cases,  the  instruments 
may  be  sterilized  in  the  tray;  the  water  poured  off;  and  the  instru- 
ments carried  to  the  operating  room  and  kept  in  the  tray,  which 
is  now  a  sterile  container.  The  nurse  should  take  care  that, 
before  the  operation,  large  quantities  of  water  are  sterilized  by 
boiling,  so  that  sufficient  may  have  cooled  off  to  permit  of  the 
tempering  of  the  solutions  used  to  a  reasonable  degree  of  heat. 
It  is  quite  probable  that  the  preparation  of  a  sufficient  supply 
of  sterile  water  will  be  quite  a  tax  on  the  kitchen  equipment — as 
the  amount  required  will  run  up  into  the  gallons. 


PART  VI— SUPPLEMENTARY 
CHAPTERS 


CHAPTER  XXVII 

GYNAECOLOGICAL  DISPENSARY 

IN  the  description  of  the  gynaecological  dispensary,  an  effort 
will  be  made  to  outline,  as  nearly  as  possible,  the  ideal  arrange- 
ment, and,  as  this  arrangement  applies  equally  to  office  work, 
the  description  will  have  a  double  application. 

1.  Records. — Every  gynaecological  dispensary  should  have  a 
card-index  filing  system,  by  which  a  continuous  record  may  be 
kept  of  the  patient's  condition  from  the  first  visit.  In  the  present 
day  of  large  dispensaries,  where  the  gynaecological  is  only  one 
of  many  branches,  this  system  is  almost  universal.  The  patient 
entering  a  large  dispensary  is  first  referred  to  the  central  or  dis- 
tributing office,  where  a  general  diagnosis  is  made  from  the 
complaint  of  the  patient,  this  process  merely  deciding  whether 
she  should  be  referred  to  the  medical,  general  surgical,  gynaeco- 
logical, or  other  branch  of  the  dispensary.  This  being  decided, 
she  is  provided  with  a  small  identification  card,  containing  only 
the  data  regarding  her  name,  the  branch  of  dispensary  to  which 
referred,  the  date  of  her  first  visit  and  the  doctor  in  charge  of 
that  particular  service.  This  card  she  retains  throughout  her 
course  of  treatment,  presenting  it  each  visit.  In  addition,  she 
is  supplied  with  a  larger  history  card,  which  is  to  be  used  as  a 
permanent  record  in  the  files,  and  upon  this  are  recorded  her  name, 
age,  occupation,  dispensary  number,  nativity,  address  and  social 
condition.  These  data  are  filled  out  at  the  central  office,  where  a 
record  of  the  same  data  is  kept.  The  patient  carries  this  card 
with  her  on  her  first  visit  to  the  dispensary,  where  the  attending 
physician  adds  a  full  history  of  the  case,  with  results  of  examina- 
tion, diagnosis  and  outline  of  treatment,  filing  it  in  his  dispensary 
records  and  making  the  necessary  notes  at  subsequent  visits. 
In  large  dispensaries  (particularly  those  of  teaching  hospitals) 
the  history  is  sometimes  taken  by  the  assistant  to  the  physician 
in  charge — the  patient  thus  coming  to  him  with  all  the  salient 
points  of  her  condition  already  outlined  and  with  the  important 
question  of  diagnosis  and  treatment  alone  left  to  him.  This 
arrangement  requires  a  suite  of  four  rooms:  (1)  the  general 
waiting  room,  in  connection  with  the  central  distributing  office; 

351 


352  SUPPLEMENTARY  CHAPTERS 

(2)  the  special  waiting  room  for  each  branch  of  the  dispensary 
(although  this  may  be  dispensed  with  by  a  proper  apportioning 
of  those  parts  of  the  general  room  that  are  in  immediate  proximity 
to  the  different  branches);  (3)  special  consultation  room,  where 
the  assistant  has  his  desk  and  takes  the  histories  of  the  successive 
patients  before  they  go  to  the  physician  in  charge;  and  (4)  the 
special  examining  and  treatment  room,  where  the  physician  in 
charge,  the  nurse,  the  examining  table  and  the  necessary  supplies 
are  found. 

Naturally,  in  private  practice,  the  central  distributing  office 
is  lacking.  The  patient  goes  from  the  waiting  room  to  the  con- 
sultation room,  where  the  physician  makes  his  own  record.  From 
there  she  goes  to  the  examining  and  treatment  room.  In  this 
case,  the  function  of  the  central  office  has  been  performed  by  the 
physician  who  has  referred  the  patient  to  a  gynaecologist  for 
special  diagnosis  or  treatment. 

2.  The  Examining  and  Treatment  Room. — This  room  should 
be  well  lighted,  both  naturally  and  artificially.  The  artificial 
lighting  should  include  an  electric  head-lamp  that  will  make 
possible  accurate  inspection  of  the  vulva,  vagina,  bladder  and 
rectum.  Where  gas  light  is  used,  a  light  and  head-mirror  should 
be  at  hand — the  light  placed  so  as  to  make  its  use  convenient 
and  satisfactory.  There  should  be  a  desk  for  the  physician, 
with  the  filing  case  and  writing  materials  conveniently  disposed. 
There  should  be  an  instrument  case  containing  the  necessary 
outfits  for  the  examination  and  treatment  of  the  bladder,  vagina 
and  rectum.  Space  should  be  supplied,  in  the  instrument  case 
or  elsewhere,  for  a  sufficient  supply  of  sterile  cotton,  sponges 
and  dressings.  The  examining  and  treatment  table  should  be 
one  of  the  standard  types,  especially  constructed  for  its  purpose 
and  of  the  particular  kind  preferred  by  the  gynaecologist  in  charge. 
In  connection  with  this  table,  there  should  be  a  surrounding 
screen  to  afford  additional  privacy  to  the  patient  and  a  foot- 
stool that  she  can  use  as  an  aid  in  mounting  the  table  and  that 
the  examiner  can  use  as  a  foot-rest  in  bimanual,  combined 
examinations.  There  should  be  at  least  two  chairs,  one  for  the 
patient  and  one  for  the  physician — and  it  is  better  to  have  more, 
as  a  gynaecological  patient  is  very  likely  to  be  accompanied  by  a 
friend  or  relative.  There  should  be  a  table  with  all  the  necessary 
instruments  arranged  upon  it  and  covered  with  a  towel,  so  that 
a  naturally  nervous  patient  may  not  be  rendered  more  so  by 
the  sight  of  glittering  instruments.  A  table  with  three  super- 


GYNECOLOGICAL  DISPENSARY  353 

posed,  swinging  shelves  is  best,  so  that  the  instruments  for 
vaginal,  rectal  and  yesical  examination  may  be  arranged  upon 
the  respective  shelves  quite  independent  of  the  other  sets  and 
conveniently  reached  when  needed.  Another  stand  should  be 
at  hand,  containing  sufficient  supplies  of  the  different  solutions, 
medicaments,  lubricant,  etc.  A  sterile  bladder-irrigating  appa- 
ratus (whether  regular  irrigator,  irrigating  syringe,  or  ordinary 
funnel  and  tube  apparatus)  should  be  always  ready  for  use.  A 
sufficient  supply  of  rubber  gloves  completes  the  ordinary  equip- 
ment of  a  properly -conducted  gynaecological  examining  and  treat- 
ment room. 

3.  Instruments. — Every  completely-equipped  gynaecological 
dispensary  should  be  supplied  with  all  the  instruments  necessary 
for  a  thorough  examination  of  the  urethra  and  bladder,  the 
vagina  and  uterus  and  the  rectum  and  sigmoid.  In  some  dis- 
pensaries it  is  customary  to  refer  those  cases  where  rectal  or 
vesical  complications  are  suspected  to  the  special  branch  having 
charge  of  these  conditions.  Diseased  conditions  of  these  three 
regions  may,  however,  be  so  closely  interrelated  as  to  make  a 
proper  differential  diagnosis  practically  impossible  without  a 
careful  examination  of  two  (or  possibly  all  three)  systems. 

The  instruments  necessary  for  vaginal  and  uterine  examina- 
tion and  treatment  are :  (1)  Specula,  which  should  be  of  different 
types  and  sizes,  to  meet  the  different  demands  that  may  be  made. 
There  should  be  two  or  three  sizes  of  the  Sims  speculum.  There 
should  be  at  least  two  sizes  of  the  Graves  or  other  good  bivalve 
speculum.  There  should  be  at  least  three  sizes  of  the  Ferguson 
or  other  tubular  speculum.  And  there  should  be  a  very  small 
tubular  speculum  (possibly  a  large  Kelly  cystoscope)  for  the 
examination  of  children.  (2)  Tenaculum  (either  single  or  double) 
or  volsellum.  (3)  Uterine  sound.  (4)  Uterine  dressing  forceps. 
(5)  Applicators.  (6)  Sponge  holders.  In  addition  to  these 
articles  of  constant  use,  there  are  a  number  of  others,  less  fre- 
quently required,  that  should  be  at  hand.  In  this  latter  group 
are  found  the  pessaries  of  various  types,  graduated  dilators  of 
the  Hanks  or  Hegar  type,  and  such  other  instruments  of  special 
application  as  may  be  required  by  the  gynaecologist  in  charge. 

The  instruments  necessary  for  urethral  and  vesical  examina- 
tion and  treatment  depend  largely  upon  the  type  of  instrument 
used  by  the  gynaecologist.  If  the  Kelly  type  of  cystoscope  be 
preferred,  the  outfit  will  differ  quite  materially  from  that  required 
for  the  electrically-lighted  instruments  that  are  used  in  a  water- 
23 


354  SUPPLEMENTARY  CHAPTERS 

distended  bladder.  The  instruments  required  for  the  Kelly 
method  of  examination  and  treatment  are,  in  addition  to  the 
head-light  or  light  and  head-mirror  already  mentioned :  a 
dilator  for  the  external  meatus;  several  tubular  bladder  specula 
with  obturators;  a  urinary  evacuator;  long  forceps  of  the  mouse- 
tooth  or  alligator  jaw  variety;  and  a  ureteral  searcher.  Ureteral 
cathetersare  also  generally  included  in  this  list,  as  of  occasional  use. 

For  the  examination  of  the  lower  bowel,  a  very  similar  class 
of  instruments  is  required  to  that  used  for  bladder  examination, 
the  difference  being  chiefly  a  matter  of  size.  The  head-light  or 
reflector  is  again  required.  A  conical  sphincter  dilator,  very 
similar  in  appearance  to  the  urethral  dilator,  is  utilized  for  gradual 
dilatation  of  the  sphincter  prior  to  the  passage  of  specula.  The 
specula  should  be  four  in  number,  varying  (unlike  the  bladder 
specula)  in  length  only.  These  are  a  short  sphincteroscope;  a 
short  proctoscope;  a  long  proctoscope;  and  a  sigmoidoscope. 
These  respective  instruments  are  particularly  adapted  to  the 
inspection  of  the  sphincter  region,  the  lower  rectum,  the  upper 
rectum  and  the  sigmoid  flexure  of  the  colon.  There  should 
also  be  a  long-handled  applicator  and  sterile  cotton  for  use  with  it. 

The  different  diagnostic  instruments  have  been  enumerated 
at  some  length,  because  it  is  important  for  the  nurse  who  has 
charge  of  them  and  who  is  responsible  for  their  care  and  prepa- 
ration to  have  an  accurate  idea  of  the  proper  use  and  grouping 
of  the  different  pieces.  All  of  the  instruments  mentioned  should 
be  in  readiness  in  a  dispensary  or  office  that  pretends  to  thor- 
oughly cover  the  field  of  gynaecological  diagnosis  and  treatment. 
In  those  cases  where  the  differentiation  from  conditions  of  the 
intestinal  or  urinary  tract  must  be  done  in  other  branches  of-  the 
dispensary,  only  the  instruments  for  vaginal  examination  are 
kept  in  the  gynaecological  room. 

4.  Preparation  for  Examination. — Every  complete  gynaeco- 
logical examination  should  consist  of  an  examination  of  the 
abdomen,  by  inspection  and  palpation,  and  sometimes  per- 
cussion; examination  of  the  vulva,  vagina  and  cervix  by 
inspection;  examination  of  the  uterus  and  appendages  by 
•combined  palpation  through  the  abdominal  wall  with  one 
hand  and  the  vagina  with  one  or  two  fingers  of  the  other  hand; 
and,  finally,  any  indicated  examinations  of  the  lower  bowel 
and  urinary  tract.  Before  taking  her  position  on  the  examining 
table,  the  patient  should  remove  her  corsets  and  free  any 
constricting  bands  about  the  abdomen  or  waist.  The  posi- 


GYNECOLOGICAL  DISPENSARY  355 

tion  used  for  the  abdominal  examination  is  the  horizontal 
recumbent — the  abdomen  being  thoroughly  exposed,  but  the 
patient  protected  from  undue  exposure  by  draping  with  sheets. 
The  positions  used  for  the  vaginal  inspection  are  generally  either 
the  Sims  or  the  dorsal.  The  latter  is  now  given  the  preference 
because  it  is  more  readily  attained;  occasions  less  incon- 
venience to  the  patient;  and  is  equally  well  adapted  to  the  subse- 
quent bimanual  combined  palpation.  The  knee-chest  position 
is  the  one  generally  employed  for  examination  of  the  bladder  or 
rectum  with  the  instruments  enumerated  above. 

5.  Drugs,  Solutions,  Etc. — This  particular  part  of  the  dis- 
pensary outfit  can,  of  course,  be  treated  in  only  the  most  general 
way — as  the  routine  of  treatment  .must  vary  markedly  with 
individual  prejudices  and  preferences.  For  the  convenience  of 
the  attending  gynaecologist,  some  solution,  as  bichloride  of  mer- 
cury 1-1000  or  carbolic  acid  1-100,  should  be  ready  in  connection 
with  the  cleansing  of  his  hands.  For  purposes  of  local  treatment 
to  the  cervix,  vagina  and  vulva,  such  medicaments  as  iodine, 
potassium  permanganate,  argyrol,  ichthyol,  etc.,  are  used  in 
solutions  of  varying  strength.  A  solution  of  boracic  acid  (from 
2  to  4  per  cent.)  is  one  of  the  most  common  for  bladder  irrigation, 
being  frequently  followed  by  the  instillation  of  a  solution  of 
argyrol  or  protargol.  Whatever  the  drugs  used  or  the  strength 
of  solution  desired,  it  should  be  the  duty  of  the  nurse  on  service 
in  the  dispensary  to  see  that  all  supplies  are  constantly  on  hand, 
in  order  to  assure  prompt  and  efficient  service. 

Draping  of  Patient  for  Examination. — For  the  combined 
gynaecological  examination,  the  dorsal  position  is  the  usual  one. 
After  the  corsets  have  been  removed  and  all  constricting  bands 
about  the  waist  loosened,  the  patient  is  placed  on  the  table  in 
this  position, — the  skirts  being  drawn  well  above  the  hips  both 
front  and  rear.  During  this  process,  the  patient  is  covered  from 
the  waist  down  by  a  sheet  thrown  lengthwise  across  her.  The 
sheet  is  then  gathered  in  the  centre  from  the  lower  edge  and 
fastened  just  above  the  pubes,  a  towel  being  placed  over  the 
vulva.  The  legs  are  then  draped  with  the  sheet,  the  ends  being 
securely  twisted  around  the  feet  of  the  patient. 

While  the  preceding  paragraphs  were  written  as  particularly 
applicable  to  the  conduct  of  a  gynaecological  dispensary  (which 
is  the  one  where  the  services  of  a  nurse  are  absolutely  indispen- 
sable), the  same  general  rules  would  apply  to  any  other  service 
to  which  the  nurse  might  be  assigned. 


CHAPTER  XXVIII 

EMERGENCIES 
I.  ACCIDENTS 

THE  surgical  nurse  will  very  properly  be  expected  to  know 
how  to  render  first  aid  in  cases  of  accident  with  which  she  may 
come  in  contact,  and  she  will  naturally  be  the  one  called  upon 
to  determine  what  is  to  be  done  when  a  physician  is  not  at  hand. 
The  conditions  under  which  she  will  then  be  compelled  to  act 
will  be  quite  different  from  those  to  which  her  training  has  accus- 
tomed her.  In  the  hospital  ward  she  is  rarely  expected  to  take 
the  responsibility  in  the  face  of  an  emergency.  Her  first  duty, 
except  in  rare  instances,  is  to  summon  the  head  nurse,  an  interne 
or  the  attending  surgeon.  When,  however,  she  is  asked  to 
render  first  aid  in  a  case  of  serious  accident  she  will  have  to 
decide  for  herself,  and  at  once,  what  is  the  best  thing  to  do,  and 
she  must  find  a  way  to  do  it,  usually  in  the  absence  of  everything 
in  the  way  of  material  or  apparatus  which  she  has  been  taught 
to  believe  essential  in  such  a  case.  The  accidental  injuries 
encountered  will  vary  infinitely  in  severity  and  in  kind,  and  there 
will  be  an  equal  variety  in  the  available  means  for  dealing  with 
them.  The  nurse  will,  perhaps,  have  to  do  something  which 
she  has  never  done  before,  but  has  only  seen  done  by  others  and 
with  every  appliance  at  hand.  The  natural  result  will  be  a  good 
deal  of  mental  confusion,  leading  perhaps  to  doing  the  wrong 
thing  or  to  doing- the  right  thing  awkwardly  and  with  unnecessary 
delay.  The  first  consideration  then  is  as  to  the  proper  habit 
of  mind  with  which  to  approach  a  problem  of  this  kind.  If  the 
mental  approach  is  right,  the  things  to  do  will  unfold  themselves 
in  the  correct  logical  order  and  the  right  thing  will  be  done 
speedily  and  efficiently. 

In  the  first  place,  first  aid  in  an  accident  is  always  a  temporary 
expedient.  We  do  not  have  to  think  at  all  of  what  is  the  proper 
treatment  in  such  cases.  The  treatment  will  be  undertaken  later 
presumably  by  competent  hands  and  with  every  needed  appli- 
ance available.  Our  object  is  to  check  the  immediate  harmful 
356 


EMERGENCIES  357 

consequences  of  the  accident,  and  then  to  hold  the  situation  in 
statu  quo  until  proper  treatment  can  be  begun.  In  the  second 
place,  there  is  always  just  one  thing  to  be  done;  i.e.,  one  crucial, 
necessary,  immediate  thing.  Other  things  may  be  needed  later, 
but  there  is  always  one  thing  to  be  done  first,  and  we  will  call 
this  the  indication.  Our  mental  approach  to  the  problem  then 
will  be  something  like  this.  First  we  ask  ourselves:  what  is  the 
indication,  what  is  the  one  immediate  thing  to  be  done?  Next, 
what  is  the  easiest  and  quickest  way  to  do  it?  Lastly,  we  will 
ask  what  means  we  have  at  hand  to  accomplish  the  action 
decided  upon.  If  we  approach  our  problem  in  this  manner  we 
shall  find  that  the  first  question  will  nearly  always  answer  itself 
immediately.  A  brief  consideration  will  enable  us  to  answer 
the  second  question,  and  when  finally  we  turn  our  attention 
to  the  available  means  at  hand,  it  is  surprising  how  easily  we 
can  find  something  that  will  answer  the  purpose. 

We  shall  discuss  in  this  chapter  very  briefly  some  of  the  more 
common  surgical  emergencies  which  the  nurse  may  at  some  time 
have  to  meet,  considering  them  from  the  standpoint  which  has 
been  suggested,  but  first  a  few  general  indications  must  be 
presented. 

The  first  is  a  warning  against  trying  to  do  too  much.  Meddle- 
some interference  in  cases  of  accident  often  does  great  and  some- 
times irreparable  harm.  In  cities  or  in  any  locality  where  an 
ambulance  or  a  physician  can  be  summoned  at  short  notice,  the 
indication,  in  a  very  large  number  of  cases,  will  be  to  do  nothing 
at  all  except  to  see  that  aid  is  summoned  promptly  and  to  ad- 
minister to  the  patient's  comfort  pending  its  arrival.  There  are 
practically  only  two  surgical  conditions  where  instant  measures 
must  be  resorted  to  in  order  to  save  life.  These  are  (1)  very 
profuse  venous  or  arterial  hemorrhage,  and  (2)  arrest  of  respira- 
tion, as  from  drowning  or  electric  shock,  or  asphyxiation  from 
inhalation  of  gas,  or  external  pressure  on  the  throat,  or  a  foreign 
body  in  the  larynx.  A  third  condition,  that  of  profound  shock 
or  collapse,  may  also  in  some  cases  call  for  prompt  measures  of 
relief.  We  shall  reserve  our  consideration  of  these  until  the  last. 

II.  WOUNDS 

Excluding  the  presence  of  active  hemorrhage,  the  indication 
for  first-aid  treatment  of  a  wound  is  the  application  of  a  sterile 
protective  covering  or  one  that  is  as  nearly  sterile  as  possible. 


358  SUPPLEMENTARY  CHAPTERS 

The  most  important  thing  is  to  keep  the  fingers  or  anything 
that  has  been  much  handled  from  contact  with  the  wound.  If 
competent  medical  aid  can  be  had  within  a  few  minutes  a  wound 
not  actively  bleeding  should  be  left  alone.  If  a  delay  of  some 
hours  is  unavoidable  a  protective  dressing  must  be  applied. 
Cleansing  of  an  extensive  wound  should  not  be  attempted  usually 
as  a  first-aid  measure.  Clots  of  blood  should  not  be  removed, 
lest  bleeding  be  started  afresh.  If  sterile  gauze  or  cotton  is 
not  at  hand  or  cannot  be  quickly  obtained  from  a  nearby  drug 
store,  some  substitute  dressing  must  be  employed.  The  thing 
to  look  for  is  something  that  has  not  been  in  contact  with  the 
human  or  animal  skin.  For  this  reason  torn  articles  of  clothing, 
while  they  answer  well  for  bandage  material,  should  not  be  used 
in  contact  with  a  wound  except  as  a  last  resort.  The  inner  folds 
of  a  clean  handkerchief,  towel  or  napkin  that  has  not  been  opened 
since  it  was  ironed  are  fairly  sterile  and  may  be  placed  in  contact 
with  a  wound  with  a  fair  degree  of  confidence  that  this  dressing 
material  will  not  be  the  means  of  carrying  septic  bacteria  into 
the  wound.  Paper  from  unhandled  original  packages  (toilet 
paper,  writing  paper)  may  be  used  if  nothing  better  is  at  hand. 
Doubtful  materials  can  be  sterilized  by  boiling  in  water  when  this 
is  possible,  or  may  be  saturated  with  an  antiseptic,  bichloride 
of  mercury  (1-3000)  or  alcohol  (for  small  wounds).  Carbolic 
acid,  except  in  very  dilute  solutions,  is  unsafe  for  large  dressings, 
and  in  strong  solutions  is  very  dangerous.  Most  of  the  commer- 
cial antiseptic  solutions  are  of  small  value.  The  best  dressing 
for  an  accidental  wound  is  dry  sterile  absorbent  gauze,  and  next 
to  this  is  a  wet  bichloride  gauze  dressing  (1-3000).  Bandages 
can  nearly  always  be  improvised  from  torn  sheets  or  clothing. 

As  has  been  indicated,  cleansing  of  an  extensive  accidental 
wound  is  not  a  first-aid  measure.  It  should  be  done  within  a 
few  hours  by  a  competent  surgeon,  preferably  at  a  hospital  where 
everything  needed  is  at  hand,  and  with  the  patient  under  an 
anaesthetic.  Necessary  operative  measures  will  be  carried  out 
at  the  same  time.  Tendons  or  nerve  trunks  may  require  to  be 
sutured,  and  partial  or  complete  closure  may  be  done.  A  very 
large  percentage  of  accidental  wounds  should  not  be  closed.  If 
cleansing  of  the  wound  is  attempted  it  is  best  done  by  flushing 
with  sterile  normal  salt  solution.  Disinfection  of  the  skin  about 
the  wound,  and  also  of  the  wound  itself,  is  most  efficiently  done 
by  equal  parts  of  tincture  of  iodine  and  alcohol. 


EMERGENCIES  359 

Infection  by  the  tetanus  bacillus  is  a  serious  danger  in  all 
wounds  infected  with  dirt  from  a  much-travelled  public  road  or 
from  a  stable  yard.  A  subcutaneous  injection  of  1500  units  of 
antitetanic  serum  is  an  almost  certain  preventive  if  promptly 
given.  The  nurse  may  regard  it  as  a  part  of  her  duty  to  help  to 
educate  the  public  to  the  conviction  that  this  preventive  measure 
should  always  be  employed  in  such  cases.  It  should  be  observed 
that  superficial  scratches  and  abrasions,  so  contaminated,  are 
not  likely  to  develop  tetanus,  since  this  organism  will  not  grow 
in  the  presence  of  oxygen.  It  is  the  deep  wounds,  particularly 
those  of  the  punctured  variety,  that  are  dangerous.  Fourth  of 
July  accidents  have  always  been  peculiarly  liable  to  tetanus 
infection.  All  such  wounds  should  be  laid  wide  open  with 
free  incisions  by  the  surgeon,  and  should  never  be  closed  by 
sutures. 

The  gas  bacillus  is  another  anaerobic  organism  which  may 
contaminate  wounds  from  the  same  source.  It  is  usually  in 
deep  and  severely  lacerated  wounds  that  this  organism  finds 
favorable  conditions  for  its  growth.  Once  started  its  develop- 
ment is  very  rapid.  The  temperature  of  a  patient  so  infected 
may  rise  to  104°  F.  within  twenty-four  hours  after  the  injury. 
Free  incisions  and  the  use  of  peroxide  of  hydrogen  are  the  best 
treatment.  The  mortality  is  very  high.  If  the  infection  is  in  a 
limb,  prompt  amputation  is  usually  necessary  to  save  life.  These 
measures  for  the  treatment  of  wounds  do  not,  of  course,  come 
within  the  province  of  the  nurse,  and  are  not  classed  as  first- 
aid  measures.  They  have  been  referred  to  here  in  order  to  empha- 
size the  necessity  of  prompt  surgical  attention  in  cases  of  deep 
punctured  or  lacerated  wounds  contaminated  with  dirt  from  the 
highway  or  from  horse  stables  and  yards. 

III.  BURNS 

The  indication  is  a  temporary  protective  covering,  mainly 
for  the  relief  of  pain.  Melted  paraffin  is  best  (page  149).  Strips 
of  gauze,  or  handkerchief  linen,  wet  with  a  solution  of  washing  or 
IK i king  soda  (a  teaspoonful  to  a  pint  of  water,  boiled),  or  picric 
acid  solution  (1-200),  answer  well.  Sterile  vaseline,  machine  oil, 
oliveoil  or  linseed  oil  may  be  used.  Carron  oil,  an  old  dressing  for 
burns,  is  an  emulsion  of.  equal  parts  of  linseed  oil  and  lime-water. 
A  dry  charred  burn  should  not  be  wet  but  dressed  with  a  dry 
sterile  dressing  lightly  bandaged. 


360  SUPPLEMENTARY  CHAPTERS 

IV.  FRACTURES 

1.  A  compound  fracture  is  one  in  which  there  is  an  open 
wound  communicating  with  the  broken  bones.     Sometimes  an 
end  of  a  fractured  bone  protrudes  through  the  wound  in  the 
skin.    In  a  compound  fracture  the  first  indication  is  a  protective 
dressing  for  the  wound.    If  the  end  of  a  bone  protrudes  it  should 
not  be  allowed  to  recede  under  the  skin.     Iodine-alcohol  disin- 
fection of  the  skin  wound  and  of  the  protruding  bone  is  good 
first-aid  practice  before  applying  the  protective  dressing. 

2.  For  simple  fractures,  in  which  there  is  no  wound,  and  for 
compound  fractures  after  the  wound  has  been  dressed  the  indi- 
cation is  fixation  of  the  fractured  bones  and,  if  possible,  of  the 
joint  on  either  side  of  the  fracture  by  means  of  some  temporary 
or  makeshift  appliance.     The  means  to  be  employed  will  vary 
with  the  location  of  the  fracture.    Clothing  should  be  cut  away 
to  expose  a  wound,  but  as  a  rule  should  be  left  in  place  over  a 
simple  fracture,  since  it  supplies  good  padding  for  the  splints. 
In  removing  clothing  remove  from  the  sound  side  first;  in  putting 
on  a  garment  start  with  the  injured  side.    No  attempt  is  to  be 
made  to  set  a  fracture,  but  a  limb  which  is  bent  at  an  angle  may 
be  gently  drawn  into  a  straight  position. 

3.  Fractures  at  the  Wrist. — A  palmar  splint  of  wood  or 
pasteboard  or  other  available  material  extending  from  the  base 
of  the  fingers  to  the  elbow  will  be  required.    The  splint  and  also 
the  back  of  the  forearm  should  be  well  padded  and  the  whole 
secured  with  a  bandage. 

4.  Fractures  of  the  Forearm. — A  palmar  and  dorsal  splint 
bandaged  on  not  too  tightly  is  the  indication.    A  palmar  splint 
fits  the  palm  of  the  hand  and  the  front  of  the  forearm  from  the 
base  of  the  fingers  to  within  an  inch  of  the  bend  of  the  elbow. 
The  width  of  the  splint  corresponds  to  the  width  of  the  forearm. 
If  a  flat  piece  of  wood  or  pasteboard  is  employed  a  half  circle 
should  be  cut  out  to  fit  the  ball  of  the  thumb.    A  dorsal  splint 
fits  the  back  of  the  hand  and  forearm  from  the  knuckles  at  the 
base  of  the  fingers  to  the  point  of  the  elbow.    If  made  of  wood 
or  other  solid  material  the  splints  should  be  well  padded.    Two 
flattened  rolls  of  newspaper,  or  any  other  paper,  make  excellent 
temporary  splints  for  a  fracture  of  the  forearm.    They  are  even 
superior  to  wooden  splints  if  skilfully  applied.     No  padding  is 
required.    A  magazine  opened  in  the  middle  and  tied  or  bandaged 
about  the  arm  will  answer  very  well.    Good  splints  can  be  made 


EMERGENCIES  361 

of  straw  or  small  twigs  by  tying  the  material  into  bundles  about 
two  or  three  inches  in  diameter.  The  splints  may  be  secured  by 
three  or  four  ties  or  a  bandage.  A  sling  must  always  be  impro- 
vised for  these  fractures.  The  coat  sleeve  or  shirt  sleeve  may 
be  pinned  to  the  part  of  the  garment  covering  the  front  of  the 
chest,  to  answer  the  purpose  of  a  sling. 

5.  Fractures  at  the  Elbow= Joint. — No  bandaging  or  splinting 
should  be  applied  to  these  fractures  as  a  first-aid  measure.     A 
well-fitting  sling  giving  smooth  support  to  the  forearm  and  hand 
and  to  the  elbow  is  all  that  should  be  attempted.    Any  make- 
shift fixation  apparatus  will  be  difficult  to  apply  and  will  rarely 
be  satisfactory.    A  bandage  is  very  apt  to  cause  dangerous  con- 
striction at  this  point  even  when  the  operator  thinks  the  bandage 
has  been  put  on  loosely. 

6.  Fractures  of  the  Upper  Arm  at  the  Shoulder,  and  of  the 
Clavicle. — In  all  these  the  indication  is  the  same,  to  fix  the  arm 
to  the  body.    The  hand  of  the  injured  side  may  be  placed  upon  the 
opposite  shoulder  if  this  position  is  comfortable,  and  the  whole 
arm  and  forearm  fixed  to  the  side  by  a  bandage  or  swathe.    In 
other  cases  the  hand  and  forearm  may  be  supported  by  a  sling. 
A  pad  made  of  a  folded  towel  or  of  paper  or  any  suitable  material 
that  is  at  hand  is  to  be  placed  between  the  arm  and  the  side.    If 
the  shoulder  injury  is,  or  may  be,  a  dislocation  instead  of  a  frac- 
ture, the  arm  may  be  held  rather  rigidly  at  a  certain  angle,  and 
in  this  case  it  should  not  be  forced  to  the  side  in  a  painful  position, 
but  should  be  supported  and  fixed  in  the  position  it  naturally 
assumes. 

7.  Fractures  of  the  Leg,  Ankle  and  Foot. — The  best  emergency 
splint  for  a  fractured  leg  is  the  pillow  splint.    The  leg  is  placed  in 
the  middle  of  a  full-sized  pillow  with  the  pillow  case  on.    The 
open  end  of  the  pillow  case  lies  at  the  foot.     The  pillow  itself 
extends  from  the  level  of  the  sole  of  the  foot  to  a  short  distance 
above  the  knee.    The  pillow  is  then  wrapped  about  the  leg  and 
edges  of  the  pillow  case  pinned  together.    The  open  end  of  the 
pillow  case  is  then  folded  about  the  sole  of  the  foot  and  pinned, 
thus  supporting  the  foot.     Four  pieces  of  bandage  or  cord  are 
then  tied  about  the  pillow,  one  above  the  knee,  one  at  the  ankle, 
and  two  between  these.    The  pillow  alone  will  answer,  but  it  is 
much  better  to  lay  four  splints  of  wood  outside  the  pillow  and 
under  the  bands,  two  behind  and  one  on  each  side.     Another 
emergency  splint  is  the  blanket  splint.    A  blanket  is  folded  so  that 


362  SUPPLEMENTARY  CHAPTERS 

its  width  is  equal  to  the  distance  from  just  above  the  knee  to  the 
sole  of  the  foot.  Two  sticks  are  provided  equal  in  length  to  the 
width  of  the  folded  blanket.  Each  stick  is  then  rolled  up  in  an 
end  of  the  blanket  until  the  two  rolls  come  in  contact  with  the  leg-, 
one  on  the  outer  side  and  one  on  the  inner  side.  The  splint  is 
then  tied  in  place.  Four  firm  rolls  of  heavy  paper,  or  straw, 
twigs  or  other  material  tied  into  bundles  about  three  inches  in 
diameter,  may  be  bandaged  about  the  leg  to  make  a  very  good 
splint.  Fractures  of  the  patella  need  no  splints  for  first  aid.  The 
leg  should  be  kept  in  a  straight  position  and  elevated.  An  ice  bag 
may  be  placed  over  the  knee. 

8.  Fractures  of  the  Thigh. — These  are  the  most  difficult  of 
all  fractures  to  handle  as  regards  the  application  of  proper  fixa- 
tion and  support  so  that  the  patient  can  be  transported  with 
comfort  and  without  injury.    First  aid  is  of  very  great  importance 
in  these  cases.     The  Thomas  splint  (Fig.  70)  is  the  ideal  appli- 
ance to  be  used  for  the  transportation  of  these  cases.    It  can  be 
put  on  without  removing  the  clothing,  extension  being  made  by 
means  of  a  clove-hitch  over  the  shoe.    With  it  a  stretcher  is  not 
necessary.    The  patient  can  be  sent  home  in  a  cab.     In  the  war 
probably  no  other  appliance  contributed  so  much  to  the  relief  of 
pain  in  the  transportation  of  wounded  men.    It  should  be  avail- 
able in  every  civilized  community  and  probably  in  time  it  will  be, 
since  so  many  surgeons  have  become  acquainted  with  its  value 
in  their  war  experience. 

In  the  absence  of  this  ideal  apparatus  probably  the  best 
method  of  preparing  a  patient  with  fracture  of  the  thigh  for  tran- 
sportation is  to  place  him  on  a  rigid  litter  or  frame  with  the  thigh 
supported  on  each  side  with  blanket  splints  and  a  small  pad  under 
the  knee.  A  door  or  shutter  may  serve  the  purpose;  or  two  or 
threeboards  maybe  fastened  together  by  cleats  nailed  across  them. 
Extension,  which  is  so'desirable  in  these  cases,  may  be'obtained  by 
rneansof  a  half  sheet  folded  and  passed  between  the  thighs,  one  end 
passing  behind  and  the  other  in  front  over  the  opposite  shoulder, 
and  fastened  to  the  head  of  the  frame.  The  other  half  of  the 
sheet  should  be  folded,  fastened  over  the  foot  and  ankle  on  the 
injured  side  by  a  clove-hitch,  drawn  tight  to  obtain  extension  and 
fastened  to  the  foot  of  the  frame. 

9.  Fracture  of  the  Jaw. — A  tight  bandage  from  the  chin  to  the 
top  of  the  head  fixing  the  lower  to  the  upper  jaw  is  all  that  is 
required  as  an  emergency  dressing. 


EMERGENCIES  363 

10.  Fracture  of  the  Ribs. — A  tight  swathe,  bandage  or  strips 
of  adhesive  plaster  about  the  chest  is  the  indication. 

11.  Dislocation. — No  attempt  need  be  made  to  distinguish 
between  fracture  and  dislocation,  when  there  is  any  doubt.    In 
case  of  any  crippling  injury  to  a  limb  the  indication  is  to  give 
the  limb  fixation  and  suppqrt  in  the  position  that  is  most  com- 
fortable for  it,  until  proper  treatment  can  be  undertaken.   First- 
aid  splinting  is  not  required  for  dislocations,  as  a  rule. 

12.  Injuries  of  the  Knee= Joint. — The  indication  is  fixation 
of  the  joint  by  a  posterior  splint,  and  elevation  of  the  leg.    An 
ire-bag  may  be  applied,  or  cold  compresses  may  be  used  to  limit 
the  effusion  and  swelling,  with  or  without  elastic  compression 
over  the  knee  by  means  of  a  bandage.     A  pillow  splint  will 
serve  the  purpose  well  as  a  first-aid  measure. 

13.  Injuries  of  the  Ankle=Joint. — If  severe,  an  injury  of  the 
ankle  should  be  treated  as  a  fracture  of  the  leg.     If  the  injury 
is  evidently  only  a  sprain,  a  firm  bandage  with  plenty  of  padding 
from  the  toes  to  the  middle  of  the  calf  is  indicated. 

14.  Injuries  of  the  Hip=Joint. — For  severe  injuries  in  this 
region  the  indication  for  fixation  and  support  is  the  same  as  for 
fi  fractured  thigh.    Most  hip  injuries  can  be  safely  transported, 
by  very  careful  handling,  without  the  aid  of  fixation  appliances. 

15.  Diagnosis   of    Injuries. — Exact   diagnosis   need   not   be 
attempted  in  doubtful  accident  cases.    It  is  the  obvious  injuries 
that  call  for  first  aid.    The  patient  will  usually  be  able  to  tell 
the  location  and  even  the  character  of  the  injury.     An  uncon- 
scious  patient  must  be   carefully  examined  to   determine  the 
extent  and  character  of  his  injuries  before  one  attempts  to  move 
him.    Gentle  lifting  and  manipulation  of  each  limb  in  turn  will 
usually  reveal  at  once  the  presence  of  a  fracture  or  dislocation. 
A  serious  wound  will  force  itself  promptly  upon  the  attention. 
When  there  is  doubt  the  clothing  must  be  removed  or  cut  away 
if  necessary.    Judgment  must  be  exercised,  of  course,  as  to  the 
severity  of  the  injury.     Slight  injuries  need  little  or  nothing  in 
the  way  of  first  aid. 

V.  TRANSPORTATION  OF  PATIENTS 

Arrangements  for  transporting  the  patient  will  usually  be 
nuido  by  the  doctor  who  is  summoned.  Frequently  the  patient 
may  have  to  be  carried  short  distances  by  those  who  render  first 
aid.  When  a  patient  can  walk  with  help  (that  is,  when  he  is  able 


364  SUPPLEMENTARY  CHAPTERS 

to  bear  part  of  his  weight  on  the  injured  foot  or  leg)  the  one  giving 
assistance  should  stand  on  the  patient's  sound  side  for  the  same 
reason  that  a  lame  man  using  one  crutch  or  a  cane  uses  it  on  the 
sound  side.  For  helpless  patients  some  substitute  for  a  stretcher 
must  be  improvised,  by  means  of  boards,  a  shutter  or  door,  or  two 
poles  with  a  blanket  or  two  coats  slung  between.  Those  carrying 
a  stretcher  from  each  end  should  be  instructed  not  to  keep  step. 
Two  men  carrying  a  patient  in  their  arms  should  be  instructed 
to  keep  step.  A  shuffling  walk  is  the  proper  gait. 

We  come  now,  finally,  to  consider  the  first-aid  measures 
which  are  of  the  greatest  importance  because  they  are  life-saving 
in  character.  The  occasions  where  they  must  be  employed  will 
come  rarely  to  any  individual,  to  many  not  at  all,  but  when  the 
occasion  does  arise  it  will  be  sudden  and  unexpected,  and  will 
tax  to  the  utmost  the  presence  of  mind  and  resourcefulness  of 
the  person  who  is  called  upon  to  act.  There  will  be  little  or  no 
time  for  reflection,  and  success  will  depend  largely  upon  clear 
understanding  of  the  situation,  and  practice  of  the  necessary 
manipulations,  so  far  as  possible,  acquired  beforehand. 

VI.  HEMORRHAGE 

1.  It  is  assumed  that  the  surgical  nurse  is  familiar  with  the 
elementary  facts  about  the  anatomy  and  physiology  of  the  cir- 
culation of  the  blood;  the  relation  of  arteries,  capillaries  and  veins; 
the  action  of  the  heart,  the  clotting  of  blood,  etc.   Her  experience 
in  the  operating  room  should  enable  her  to  recognize  the  appear- 
ance of  a  spouting  artery,  the  darker  blood  flowing  from  a  vein 
and  the  general  oozing  of  capillary  hemorrhage.    We  shall  first 
enumerate  briefly  the  several  methods  for  controlling  hemorrhage 
in  accidental  wounds;  next  we  shall  consider  the  bearing  which 
the  location  of  the  wound  may  have  upon  the  problem  of  control 
of  hemorrhage,  and  finally  we  shall  point  out  the  indications  to 
be  followed  under  the  different  conditions  which  may  be  en- 
countered. 

2.  Methods   for   the    Control   of    Hemorrhage. — The   most 
efficient  method  for  the  control  of  hemorrhage  is  the  ligature. 
A  small  pinch  of  tissue  at  the  bleeding  point  is  clamped  with 
forceps  of  one  of  the  several  patterns  in  use.    A  ligature  of  sterile 
silk,  linen,  or  catgut  is  then  tied  tightly  about  the  tissue  under 
the  point  of  the  clamp  in  a  double  knot.     Or  the  ligature  is 
threaded  into  a  curved  needle,  passed  through  the  tissue  under 


EMERGENCIES  365 

the  point  of  the  clamp  and  tied.  The  latter  method  is  used  where 
the  tissue  is  either  very  friable  or  very  dense.  These  methods 
are  a  part  of  the  operative  technic  and  the  nurse  will  see  them 
constantly  employed  during  her  operating-room  experience. 
They  are,  however,  not  available  ordinarily  in  cases  of  accident, 
since  the  necessary  instruments  and  ligatures  will  rarely  be  at 
hand  or  easily  accessible.  We  must,  therefore,  as  a  rule,  rely 
upon  other  methods  for  the  immediate  arrest  of  hemorrhage 
in  cases  of  accidental  wounds.  These  include,  first,  elevation 
of  the  part,  which  has  important  but  limited  uses;  second,  pres- 
sure in  some  form,  the  method  of  greatest  importance  and  widest 
application;  and,  third,  the  use  of  means  which  either  cause 
contraction  of  the  small  divided  vessels  or  hasten  the  coagula- 
tion of  the  blood.  These  latter  methods  include  heat  and  cold 
and  the  styptic  or  astringent  drugs. 

(1)  Elevation  of  the  Part. — This  method  is  applicable  only 
to  the  hand  and  arm,  or  the  foot  and  leg.     It  is  effective  for 
venous  and  capillary  hemorrhage,  but  will  not  control  bleeding 
from  an  artery,  although  it  somewhat  diminishes  the  force  of 
the  arterial  stream  and  is  therefore  of  use  in  conjunction  with  other 
methods,  even  in  arterial  hemorrhage. 

(2)  Digital  Compression  of  the  Brachial  or  Femoral  Artery.— 
Almost  all  the  blood  flowing  to  an  arm  or  leg  can  be  instantly  cut 
off  by  pressing  the  main  arterial  trunk  which  supplies  the  limb 
between  the  fingers  and  a  bony  surface.    For  the  brachial  artery 
the  inner  border  of  the  biceps  muscle  at  the  middle  of  the  upper 
arm  marks  the  place  where  the  artery  can  readily  be  compressed 
against  the  bone.     The  hand  grasps  the  biceps  with  the  tips 
of  the  fingers  at  its  inner  border  and  the  thumb  on  the  outer 
side  of  the  arm.     The  fingers  feel  for  the  pulsating  artery  and 
compress  it  against  the  bone.    With  the  arm  raised  the  axillary 
artery  can  be  compressed  against  the  head  of  the  humerus, 
under  the  anterior  axillary  fold.    These  manoeuvres  can  be  easily 
learned  by  a  little  practice.     The  femoral  artery  can  be  felt  in 
the  groin  just  below  Poupart's  ligament,  where  it  passes  over  a 
bony  prominence.    Strong  pressure  with  both  thumbs  will  usually 
be  necessary  to  control  it.     Compression  of  other  large  arterial 
trunks,  such  as  the  common  carotid,  the  subclavian  and  even 
the  abdominal  aorta,  can  be  done  with  the  fingers  in  some  cases, 
but  is  too  difficult  and  uncertain  to  be  recommended  to  a  novice. 

(3)  Flexion. — Strong  flexion  at  the  knee  or  elbow,  with  a 


366  SUPPLEMENTARY  CHAPTERS 

small  pad  between  the  flexed  surfaces,  may  suffice  to  check 
hemorrhage  from  deep  arteries  in  the  foot  and  hand,  which  being 
protected  by  the  plantar  or  palmar  fascia  are  sometimes  difficult 
to  control  by  direct  pressure. 

(4)  The    Tourniquet. — Many   forms    of    this    appliance    are 
described  in  the  older  surgeries.    The  only  one  now  in  practical 
use  in  the  operating  room  is  the  elastic  rubber  band.    An  emer- 
gency tourniquet  is  made  from  a  handkerchief,  cravat,  belt  or 
strip  of  cloth  torn  from  the  clothing,  tied  loosely  about  the 
limb,  and  twisted  tight  with  a  stick.     Such  a  tourniquet  is  to 
be  applied  only  about  the  thigh  or  upper  arm.    It  is  useless  about 
the  forearm  or  leg.     It  should  always  be  placed  at  least  four 
inches  above  the  injured  tissues,  and  should  be  applied  outside 
the  clothing  or  with  some  form  of  padding  under  the  band.    It 
should  never  be  allowed  to  remain  in  place  more  than  three  hours. 

(5)  Pressure  by  a  Bandage. — A  tight  bandage  applied  over  the 
wound  dressing  will  control  hemorrhage  unless  there  is  bleeding 
from  a  deep  vessel  which  is  protected  from  pressure  by  anatomical 
structures,  as  for  example  the  deep  palmar  arch  in  the  hand.    A 
pressure  bandage  applied  to  a  limb  should  extend  from  the 
fingers  or  toes  up. 

(6)  Packing  the  Wound. — The  nurse  will  probably  see  this 
method  applied  [during  her  operating-room  experience.      The 
essential  thing  is  that  every  crevice  of  the  wound  shall  be  filled 
with  the  packing  material,  so  that  equal  pressure  is  made  over 
the  whole  of  the  raw  surface.    It  is  not  recommended  as  a  first- 
aid  measure  unless   the   proper  materials  are  at  hand  or  the 
necessities  of  the  case  require  it.    It  involves  cleansing  the  wound. 
Packing  is  useless  in  the  presence  of  clots.     Sterile  materials 
must  be  employed  if  possible. 

(7)  Direct  Pressure. — This  means  that   the  thumb  or  first 
finger,  or  a  small  pad  held  by  the  fingers,  is  thrust  directly  into 
the  wound  and  pressed  against  the  bleeding  vessel  at  the  point 
where  it  is  wounded.    This  is  the  simplest,  easiest  and  quickest 
method  for  temporary  control  of  the  bleeding  from  a  wounded 
artery  or  vein.    The  objection  to  it  in  accident  cases  is  that  the 
fingers  are  always  dirty,  in  the  surgical  sense  at  least,  and  when 
they  are  brought  in  contact  with  the  wound  the  chances  of  infec- 
tion are  greatly  increased.    Accidental  wounds  are  presumably 
always  infected,  but  as  a  matter  of  fact  many  of  them  will  heal 
primarily  if  they  are  not  handled,  whereas  nearly  all  of  those 


EMERGENCIES  367 

that  are  handled  will  suppurate.  The  method  of  direct  pressure 
is  in  constant  use  in  the  operating  room;  the  surgeon  presses  his 
gloved  finger  or  a  gauze  sponge  on  the  bleeding  point  even  while 
he  is  reaching  for  a  clamp.  In  accident  cases  the  method  is  to 
be  reserved  for  those  cases  of  violent  hemorrhage  from  large 
vessels  which  must  be  checked  instantly  if  life  is  to  be  saved.  All 
risks  of  infection  are,  of  course,  to  be  disregarded  rather  than 
let  a  patient  bleed  to  death.  When  the  bleeding  vessel  is  once 
under  the  control  of  the  finger,  very  moderate  pressure  will  be 
found  to  be  sufficient,  and  it  can  be  easily  maintained  for  any 
length  of  time  that  is  necessary. 

(8)  Heat  and  Cold. — Hot  water  is  the  most  efficient  means 
for  the  control  of  capillary  oozing.    An  ice-bag  is  useful  to  control 
subcutaneous  bleeding. 

(9)  Styptic  or  Astringent  Drugs. — These  are  useful  only  for 
capillary  bleeding.    They  are  not  to  be  recommended  in  first- 
aid  treatment. 

3.  The  Indications  for  the  Control  of  Hemorrhage  According 
to  Character  and  Location. — In  cases  of  hemorrhage  from  wounds 
of  the  extremities  or  of  the  scalp  we  have  the  consoling  thought 
that  the  bleeding  can  always  be  controlled.  A  tight  band  about 
the  head  will  check  bleeding  from  a  scalp  wound,  and  a  pressure 
bandage  over  the  dressing  will  control  it.  If  there  are  clots  under 
the  sculp  those  should  be  first  pressed  out,  as  pressure  will  not 
be  efficient  while  they  remain.  In  active  hemorrhage  from 
wounds  of  the  arm  or  leg  the  first  indication  is  elevation  of  the 
part;  the  next  is  digital  pressure  on  the  main  artery.  If  the 
bleeding  is  profuse  a  tourniquet  can  then  be  put  on  and  tightened 
sufficiently  to  chock  the  flow.  With  this  in  place  the  wound  may 
be  dressed  at  leisure  and  a  firm  bandage  applied.  The  tourniquet 
can  then  be  loosened,  but  left  in  place  to  be  tightened  again  if 
necessary. 

A  ruptured  varicose  vein  may  result  in  a  fatal  hemorrhage 
in  a  surprisingly  short  time  (five  or  ten  minutes)  if  the  patient 
remains  sianding  or  sitting  in  a  chair.  The  recumbent  position 
with  elevation  of  the  leg  will  check  the  bleeding  instantly.  A 
small  pad  bandaged  over  the  bleeding  point  will  control  it. 

Superficial  wounds  of  the  trunk,  except  at  the  points  where 
the  groat  vessels  pass  to  the  extremities  and  the  head,  rarely 
givo  rise  to  serious  hemorrhage.  Pressure  bandages  over  the 
dressing,  or  sometimes  over  packing  in  the  wound,  are  the  only 


368  SUPPLEMENTARY  CHAPTERS 

means  of  control  as  a  first-aid  measure.  Hemorrhage  into  the 
great  cavities  of  the  body,  as  the  result  of  penetrating  wounds 
in  the  chest  or  abdomen,  is  beyond  the  resources  of  those  who 
give  first  aid,  and  often  beyond  the  resources  of  surgery. 

Wounds  of  the  great  vessels  at  the  root  of  the  neck,  in  the 
axilla,  and  in  the  groin,  give  rise  to  frightfully  violent  hemor- 
rhages, which  may  result  fatally  in  from  two  to  five  minutes. 
In  such  cases  there  is  nothing  for  it  but  to  plunge  the  finger  into 
the  wound  and  find  and  compress  the  opening  in  the  vessel 
itself.  The  rushing  blood  may  guide  the  finger  to  the  spot.  Once 
it  is  found  the  bleeding  stops  instantly,  and  after  that  only 
moderate  pressure  is  required,  so  that  the  situation  can  be  kept 
under  control,  without  undue  exhaustion,  even  for  many  hours 
if  necessary.  Of  course,  not  all  the  cases  will  come  within  the 
compass  of  this  desperate  remedy,  and  the  opportunities  for 
attempting  it  will  be  extremely  rare,  but  if  the  chance  comes 
it  should  not  be  missed  for  want  of  knowledge  or  of  alertness. 
If  the  manoeuvre  is  successful  and  the  opening  in  the  vessel 
has  been  plugged  by  the  finger,  then  the  patient's  life  is  saved, 
barring  later  complications  which  need  not  be  considered  for 
the  moment.  If  the  bleeding  is  from  a  wound  in  one  of  the  great 
veins  the  after-procedure  is  comparatively  simple.  Firm  pres- 
sure through  the  skin  in  the  course  of  the  vein  on  the  side  of  the 
wound  away  from  the  heart,  and  pressure  at  the  same  time  on 
the  side  toward  the  heart,  will  usually  control  the  bleeding  while 
the  finger  is  gently  withdrawn  and  a  tight  gauze  or  handkerchief 
pack  substituted  for  it.  This  can  be  kept  in  place  by  pressure 
with  the  hand,  or  a  heavy  weight  may  be  placed  over  it  and 
secured  in  position  by  a  bandage.  With  a  bandage  alone  in 
these  situations  it  may  be  difficult  to  make  efficient  pressure. 

With  a  wound  in  one  of  the  main  arterial  trunks  the  case  is 
quite  different.  Packing  will  not  control  the  hemorrhage  and 
the  finger  must  be  kept  in  place  until  a  ligature  or,  at  least,  a 
clamp  can  be  applied.  This  means  a  delay  not  only  until  the 
arrival  of  the  surgeon  but  also  until  he  has  had  ample  time  to 
prepare  for  an  operation.  The  thing  to  do  is  deliberately  to 
manoeuvre  the  patient  and  oneself  into  a  position  as  easy  and 
comfortable  as  possible,  carefully  relax  pressure  until  just  about 
the  least  amount  necessary  is  determined,  then  vigilantly  main- 
tain that  pressure  and  prepare  for  a  long  wait.  The  ceaseless 
drumming  of  a  great  artery  against  the  finger  may  sorely  try 


EMERGENCIES  369 

the  nerves  of  the  imaginative,  or  even  of  the  most  phlegmatically 
disposed.  Safety  lies  in  keeping  always  before  the  mind  the 
simple  fact  that  the  situation  is  absolutely  under  control.  Even 
a  slight  muscular  effort  becomes  very  trying  when  continued  for 
a  long  time.  Intelligent  attention  must  be  directed  to  minimizing 
fatigue,  by  avoiding  unnecessary  exertion  in  making  pressure, 
by  slightly  changing  the  position  of  the  fingers  from  time  to  time 
so  as  to  shift  the  effort  from  one  group  of  muscles  to  another, 
and  sometimes  by  resting  a  padded  weight  upon  the  hand. 

Hemorrhage  from  the  mucous  membranes  in  the  mouth,  nose, 
vagina,  or  rectum  is  not  often  severe  enough  to  be  immediately 
dangerous.  The  application  of  cold  externally  and  of  ice  water 
within  the  cavities  is  the  first  indication.  Hemorrhages  from  the 
stomach  (hsematemesis)  and  from  the  lungs  (haemoptysis)  are 
medical  and  not  surgical  conditions. 

VII.  ARTIFICIAL  RESPIRATION 

The  principal  indications  for  the  employment  of  artificial 
respiration  are  drowning,  and  asphyxiation  by  illuminating  or 
other  gas.  To  these  the  most  recent  industrial  conditions  have 
added  one  more,  that  of  electric  shock. 

There  are  two  methods  of  artificial  respiration  in  use  at  the 
present  time,  known  as  the  Silvester  method  and  the  Shafer 
method.  The  latter  is  by  far  the  more  efficient.  In  addition  there 
are  now  upon  the  market  several  very  efficient  machines  for  the 
production  of  artificial  respiration  (pulmotor,  lungmotor). 
Most  hospitals  will  be  supplied  with  one  of  these.  In  the  Silvester 
method  the  patient  lies  upon  his  back,  in  the  Shafer  method  upon 
his  face.  For  this  reason  the  less  efficient  Silvester  method  is  the 
one  which  must  usually  be  employed  when  respiration  fails  upon 
the  operating  table.  A  patient  cannot  be  turned  upon  his 
face  in  the  midst  of  an  operation,  particularly  an  abdominal 
operation.  In  the  Silvester  method  two  operators  are  almost 
essential  for  efficient  work.  One  on  either  side  of  the  patient 
grasps  an  arm  and  lifts  it  strongly  above  the  patient's  head.  The 
two  arms  are  then  brought  down  across  the  patient's  chest,  and 
pressure  is  made  on  the  lower  ribs,  thus  forcing  the  air  out  of 
the  lungs.  The  two  manoeuvres  are  repeated  about  fifteen  times 
a  minute  until  the  patient  begins  to  breathe  naturally. 

Professor  Shafer  describes  his  method  as  follows:  "Lay  the 
subject,  face  downward,  upon  the  ground,  with  the  arms  stretched 
24 


370 


SUPPLEMENTARY  CHAPTERS 


above  the  head  and  the  face  to  one  side.  The  operator  should 
at  once  place  himself  in  position  astride  or  at  one  side  of  the 
subject,  facing  his  head  and  kneeling  upon  one  or  both  knees. 
He  then  places  his  hands  flat  over  the  lower  part  of  the  back 


FIG.  133. — Shafer  method  of  artificial  respiration.    First  position:  inspiration;  pressure  off. 

(on  the  lowest  ribs),  one  on  each  side,  and  gradually  throws  the 
weight  of  the  body  forward  on  them  so  as  to  produce  firm  pressure, 
which  must  not  be  violent,  or  upon  the  patient's  chest.  By  this 


FIG.  134. — Shafer  method  of  artificial  respiration.    Second  position :  expiration ;  pressure  on. 

means  air  and  water,  if  any  is  present,  are  forced  out  of  the 
patient's  lungs.  Immediately  thereafter  the  operator  raises  his 
body  slowly  so  as  to  remove  the  pressure,  but  the  hands  are  left 
in  position.  This  forward  and  backward  movement  is  continued 


EMERGENCIES  371 

every  four  or  five  seconds.  In  other  words,  the  body  of  the 
operator  is  swayed  slowly  forward  and  backward  upon  the  arms 
from  12  to  15  times  a  minute,  and  this  should  be  continued  for 
at  least  half  an  hour  or  until  the  natural  respirations  are  resumed  " 
(Figs.  133  and  134). 

VIII.  SHOCK  IN  ACCIDENT  CASES 

If  there  has  been  no  hemorrhage  the  shock  resulting  from  an 
accident  is  a  condition  akin  to  exhaustion  from  great  exertion, 
as  explained  in  the  chapter  on  anoci-association.  It  is  due  to 
great  emotional  stress  and  the  direct  effect  of  the  trauma  upon 
the  cells  of  the  brain.  Absolute  rest  and  quiet,  and,  above  all,  sleep, 
with  the  application  of  external  warmth,  are  the  indications.  It 
is  good  practice  to  give  a  small  hypodermic  of  morphia,  but  this 
should  never  be  done  if  cyanosis  is  present.  Fluids  should  be  given 
by  mouth,  or  in  the  severer  cases  a  solution  of  5  per  cent,  glucose 
and  5  per  cent,  sodium  carbonate  by  rectum  by  the  Murphy 
method  (page  146) .  Calm  assurance  and  confidence  on  the  part  of 
those  who  attend  the  patient  with  active  attention  to  his  comfort 
in  every  particular,  are  factors  of  importance  in  the  treatment  of 
shock.  Sleep  should  be  encouraged  by  every  means  and  never 
interrupted  except  for  the  most  urgent  reasons.  When  extensive 
hemorrhage  has  occurred  another  factor  is  added  in  the  condition 
of  shock  for  which  active  treatment  may  be  required.  The  po- 
sition with  the  head  lowered  and,  in  bad  cases,  firm  bandaging  of 
the  extremities,  from  the  toes  to  the  groin,  and  from  the  fingers  to 
the  shoulder,  are  indicated  in  order  to  save  all  the  blood  available 
to  supply  the  brain  and  the  heart.  Warm  saline  solution  should 
be  given  by  rectum  or  subcutaneously,  the  latter,  of  course,  .only 
under  strict  aseptic  conditions.  Transfusion  of  blood,  the  ideal 
treatment  for  grave  cases  of  hemorrhage,  does  not  come  within 
the  province  of  the  nurse. 


CHAPTER  XXIX 
THE  PERSONAL  ATTITUDE  OF  THE  NURSE 

THE  personal  attitude  of  the  nurse  is  so  closely  dependent 
upon  individual  characteristics  and  the  demands  of  particular 
circumstances  that  it  is  only  with  great  difficulty  that  rules,  or 
even  suggestions,  for  governing  it  can  be  outlined.  It  is  true, 
however,  that  in  her  multifarious  relations  with  the  hospitals, 
with  the  individual  sufferer,  with  the  public  at  large  and  with 
the  medical  profession,  the, question  as  to  what  her  duty  is  in  a 
particular  case  must  often  arise.  And,  necessarily,  each  of  these 
problems  must  be  to  some  extent  related  to  the  duty  to  self. 
The  effort,  here,  will  then  be  to  outline,  at  times  generally  and  at 
others  specifically,  what  attitude  her  duty  requires  in  these,  her 
several  relations. 

I.  ATTITUDE  TO  THE  PATIENT 

Of  course,  the  first  duty  of  the  nurse  (as  of  the  physician  or 
the  surgeon)  is  to  the  patient  upon  whom  she  is  attendant. 
This  duty  consists,  broadly,  in  bringing  into  play  all  of  those 
resources  that  have,  by  her  training,  been  placed  at  her  command 
for  the  relieving  of  the  discomfort  and  suffering  to  which  the 
patient  is  subject.  The  three  cardinal  virtues  of  the  trained 
nurse  are  competency,  cheerfulness  and  reserve.  It  may  be 
safely  assumed  that  the  first  of  these  exists  in  the  great  majority 
of  trained  nurses,  whether  graduate  or  undergraduate.  But  the 
other  two  are  only  in  a  degree  less  important  and,  probably, 
where  not  naturally  possessed,  more  difficult  of  attainment.  And 
even  cheerfulness,  which  is  in  itself  a  gift,  may  be  quite  without 
avail  if  devoid  of  the  balance  of  reserve.  One  may  have  a  ready 
smile;  a  willingness  to  perform  unceasingly  and  without  complaint 
the  numerous  small  and  tiring  routine  measures  for  the  comfort 
of  the  patient;  a  readiness  to  put  up  with  minor,  or  even  consider- 
able, discomforts;  and  a  ready  flow  of  interesting  conversation 
when  the  condition  of  the  patient  seems  to  warrant  or  require 
this  diversion.  But  natural,  or  acquired,  reserve  should  warn  the 
nurse  that,  at  times,  silence  is  more  acceptable  than  the  brightest 
conversation;  that  her  conversation  should  never  include  the 
372 


THE  PERSONAL  ATTITUDE  OF  THE  NURSE  373 

interesting  (and  sometimes  morbid)  details  of  other  cases;  and 
that,  above  all  and  before  all,  any  information,  no  matter  how 
trivial,  obtained  in  her  professional  capacity  is  under  a  seal  that 
must  be  absolutely  inviolate. 

II.  ATTITUDE  TO  THE  SURGEON 

The  attitude  or  duty  of  the  nurse  to  the  surgeon  must,  neces- 
sarily, bear  an  intimate  relation  to  her  attitude  to  the  patient. 
She  must  assume  that  he  is  competent  to  outline  properly  the 
treatment  and  she  must  see  that  his  orders  are  faithfully  executed. 
She  must  keenly  and  closely  observe  and  record  the  varying  con- 
dition of  the  patient  from  time  to  time,  and,  in  case  of  emergency, 
see  that  the  surgeon  is  promptly  notified.  She  must  be  suffi- 
ciently familiar  with  the  dosage  and  method  of  administration 
of  powerful  drugs  to  prevent  errors  of  carelessness  or  ignorance 
in  administration.  And  she  should  observe  absolute  and  unwaver- 
ing loyalty  to  the  surgeon,  where  this  does  not  certainly  encroach 
upon  her  first  loyalty  to  the  patient. 

This  last  statement  brings  up  one  of  the  most  delicate  points 
in  the  relations  of  the  nurse  to  her  environment.  By  all  just 
reasoning,  her  first  duty  is  to  the  patient.  But  she  also  owes  an 
undoubted  loyalty  to  the  surgeon.  And  besides  this  loyalty, 
it  must  be  presupposed  that  the  broader  education  and  greater 
experience  along  these  lines  of  the  surgeon  will  make  him  better 
fitted  to  judge  of  what  is  best  for  the  patient  than  can  be  possible 
for  the  nurse.  Nevertheless,  occasions  do  arise  when  the  compe- 
tent nurse  becomes  convinced  that  the  treatment  outlined  for 
the  patient  is  wrong  and,  possibly,  harmful.  In  this  case,  wherein 
lies  her  duty?  In  hospitals,  the  responsibility  may  fairly  be 
placed  upon  the  superintendent  of  nurses  and  the  medical  staff 
of  the  hospital.  In  private  practice,  however,  the  solution  is 
not  so  simple.  First,  it  is  difficult  for  the  well-balanced  nurse 
to  assure  herself  that  her  doubts  are  well  founded.  Second,  if 
she  speaks  to  the  patient,  without  consulting  the  surgeon,  she 
will  have  been  disloyal  to  the  latter,  possibly  without  benefiting 
the  patient,  who  may  discharge  the  nurse  and  retain  the  surgeon. 
Third,  if  she  speaks  first  to  the  surgeon,  she  may  be  discharged 
without  opportunity  to  benefit  the  patient.  The  best  and  safest 
solution  of  this  difficult  problem  would  appear  to  be:  (1)  that 
the  nurse  assume  that  the  surgeon  is  competent,  conscientious 
and  correct,  until  she  is  forced  to  a  contrary  decision;  (2)  that 


374  SUPPLEMENTARY  CHAPTERS 

she  then  verify  by  the  best  means  at  her  disposal  her  doubts, 
preferably  consulting  some  more  experienced  person,  as  the  super- 
intendent of  the  training  school  from  which  she  graduated;  (3) 
that  she  then,  if  further  convinced,  inform  the  family  of  the 
patient  of  her  doubts  and,  after  this  warning,  terminate  her  con- 
nection with  the  case;  (4)  that  she  notify  the  surgeon  of  her  action; 
and  (5)  that  she  carefully  refrain  from  suggesting  or  recommend- 
ing any  substitute  or  consultant  for  the  regular  attendant.  By 
pursuing  such  a  course,  the  nurse  will  have:  (1)  avoided  acting 
with  undue  precipitance;  (2)  performed  her  duty  to  the  patient; 
(3)  avoided  the  possibility  of  suspicion  of  ulterior  motive  on  her 
part;  (4)  been,  at  least,  honest  and  open  with  the  surgeon;  and 
(5)  conducted  herself  with  due  regard  to  decorum. 

It  is  possibly  well  to  caution  the  nurse  against  at  any  time 
indulging  in  comment  to  the  patient,  whether  of  praise  or  of 
criticism,  concerning  the  ability  of  other  surgeons  than  the  attend- 
ant. There  sometimes  arises,  in  this  connection,  a  feeling  that 
the  nurse,  for  one  reason  or  another  (even  where  no  such  inten- 
tion exists),  desires  to  create  a  comparison  to  the  discredit  of 
one  practitioner,  a  course  which,  at  best,  is  as  unwise  as  it  is 
discourteous. 

III.  ATTITUDE  TO  THE  HOSPITAL 

The  nurse,  whether  undergraduate  or  graduate,  who  is  en- 
gaged in  hospital  work,  must  occupy  one  of  two  positions  to  that 
institution,  being  either  a  member  of  the  working  organization, 
an  integral  part  of  the  official  family  or  a  guest  to  whom  the 
courtesy  of  the  institution  has  been  extended.  In  the  one  case, 
she  owes  at  least  community  loyalty,  and,  in  the  other,  an  obser- 
vance of  the  ordinary  laws  of  hospitality.  This  means  that  it 
is  her  duty,  so  long  as  she  remains  within  the  hospital,  to  observe 
the  internal  rules  of  the  institution.  Her  care  of  and  attention  to 
the  patient  must  consider  not  only  those  duties  that  exist  from  a 
nurse  to  a  patient,  but  must,  also,  include  an  endeavor  so  to 
perform  her  duties  that  no  criticism  of  the  hospital  may  come 
from  the  patient,  as  a  result  of  her  fault.  It  is  frequently  from 
the  attention  or  inattention  of  individual  nurses  that  patients 
form  their  opinions  of  a  hospital,  and  it  is  upon  the  impressions 
of  these  patients  that  their  friends  decide  as  to  the  merits  or 
demerits  of  a  particular  institution.  It  is  not  desired  to  suggest 
that  a  good  nurse  can  offset  all  the  defects  of  a  badly-managed 


THE  PERSONAL  ATTITUDE  OF  THE  NURSE  375 

and  ill-conducted  hospital,  but  it  is  undoubtedly  the  fact  that  a 
careless,  inattentive  or  neglectful  nurse  may  undo  the  good 
impression  that  would,  otherwise,  be  left  by  a  perfectly-organized 
institution. 

IV.  ATTITUDE  TO  THE  PUBLIC 

The  individual  who  enters  upon  a  career  that  has  for  its 
purpose  the  cure  or  care  of  the  sick  accepts  a  broader  responsi- 
bility than  that  of  conscientious  service  to  each  individual  sufferer. 
The  constant  trend  of  modern  advance  in  the  allied  forces  of  the 
medical  professions  is  towards  the  accomplishment  of  two  ends, 
not  in  themselves  directly  aimed  at  the  cure  of  individual  cases: 
(1)  the  prevention  of  disease  and  (2)  the  early  diagnosis  of  certain 
conditions  in  which  the  early  institution  of  treatment  offers 
the  chief  hope  of  cure.  While  the  nurse  cannot  be  the  prime 
factor  in  either  of  these  movements,  her  position  as  a  trained 
member  of  one  of  the  branches  of  these  forces  imposes,  upon  her 
a  responsibility  that  cannot  well  be  avoided.  Her  advice  will 
be  frequently  sought  by  relatives,  friends  and  even  mere  ac- 
quaintances. Some  of  these  opportunities,  possibly  the  majority, 
will  be  outside  the  relatively  narrow  field  considered  in  this 
volume,  but  the  nurse  whose  wise  counsel  has  contributed  to  the 
early  diagnosis  of  a  case  of  pulmonary  tuberculosis,  of  carcinoma 
of  the  breast,  stomach  or  uterus;  or  has,  by  impressing  upon  the 
prospective  mother  the  necessity  for  competent  medical  super- 
vision throughout  pregnancy,  aided  in  forestalling  a  threatened 
attack  of  eclampsia,  may  well  feel  that  she  has  contributed  her 
mite  to  the  grand  sum  total  of  the  effort  of  her  fellow  workers. 

V.  ATTITUDE  TO  SELF 

While  the  profession  of  nursing  must  be  largely  based  upon 
altruism,  yet  the  nurse  who  utterly  neglects  herself  will  soon 
resign,  perforce,  the  care  of  others.  A  fair  general  rule  would 
be  for  the  nurse  to  take  as  good  care  of  herself  as  the  best  interests 
of  her  patient  will  permit.  If  the  last  case  has  drawn  too  heavily 
upon  the  vitality,  do  not  undertake  the  care  of  the  next  until 
properly  recuperated.  When  working  under  a  steady  strain, 
do  not  depend  upon  the  stimulus  of  excessive  tea  and  coffee 
drinking  for  support.  If  unable  to  rest  when  you  should,  do  so 
when  you  can.  Be  sure  to  get  some  exercise  in  the  fresh  air  and 
sunshine  each  day,  even  though  rest  seems  more  desirable  and 


376  SUPPLEMENTARY  CHAPTERS 

fatigue  prevents  enjoyment.  When  the  body  is  under  a  heavy 
physical  and  nervous  strain,  do  not  make  matters  worse  by  adding 
an  excessive  burden  to  the  digestive  tract.  Eat  what  is  nourish- 
ing, simple  and  easily  digested,  preferably  at  all  times,  but 
certainly  when  on  hard  duty. 

The  keynote  to  the  attitude  of  the  nurse  towards  any  part 
of  her  work  or  in  any  of  her  relations  must  be  found  in  her  atti- 
tude towards  the  work  itself.  If  she  feels  that  the  work  is  worth 
while  and  that  her  best  efforts  are  none  too  good  for  it,  there  is 
little  danger  of  her  falling  short  in  her  duty.  The  chief  danger 
seems  to  lie  in  the  changes  effected  by  the  period  of  training, 
when  all  of  her  values  must  be  readjusted  so  as  nicely  to  maintain 
the  balance  between  the  ideal  as  conceived  and  the  real  as  prac- 
tised. It  is  at  this  time  that  the  ideals  may  be  lost  and  the  real 
nurse  hidden  under  the  veneer  of  cynicism  that  has  become  so 
usual  a  part  of  the  life  of  to-day.  And  it  is  this  that  we  most 
wish  to  avoid.  If  there  are  any  attributes  that  the  nurse  should 
retain  as  an  essential  part  of  her  equipment,  the  leading  should 
be  her  natural  sympathies  and  her  natural  or  acquired  ideals. 
These  she  should  maintain  amidst  the  most  repulsive  exhibitions 
of  disease  and  the  most  sordid  exhibitions  of  human  degradation, 
retaining  them,  if  necessary,  upon  no  other  evidence  than  that  of 
faith  alone,  "  the  substance  of  things  hoped  for,  the  evidence 
of  things  not  seen.  " 


CHAPTER  XXX 

AN    EPITOME    OF    SOME    COMMON    SURGICAL   AND 
GYNECOLOGICAL  CONDITIONS 

IN  this  chapter  a  brief  outline  will  be  given  of  some  of  the 
more  common  surgical  conditions  which  the  nurse  will  encounter 
in  hospital  and  private  practice.  The  object  sought  will  be  not 
to  teach  how  to  make  a  diagnosis  or  how  to  treat  a  case,  since 
these  are  not  within  the  province  of  the  nurse,  but  to  aid  her  to 
obtain  an  intelligent  understanding,  though  necessarily  general 
and  superficial  in  character,  of  the  surgical  diseases  and  affec- 
tions which  come  under  her  care.  Particular  emphasis  will  be 
given  to  the  nursing  aspects  of  the  case  so  far  as  possible  in  the 
space  available. 

I.  MALFORMATIONS  AND  ANATOMICAL  DEFECTS  AND 
DERANGEMENTS 

A.  CONGENITAL  DEFORMITIES 

Cleft  Palate  and  Hare=lip.  Definition. — In  single  hare-lip 
there  is  a  cleft  of  the  lip  extending  into  the  nostril  on  one  side  of 
the  mid-line,  more  often  the  left.  In  double  hare-lip  there  are  two 
clefts  with  a  projecting  mass  between  (intermaxillary  bones  and 
mid-lip  or  prolabium), attached  to  the  nasal  septum.  Cleft  palate 
is  a  cleft  in  the  mid-line  of  the  roof  of  the  mouth,  either  partial 
or  complete,  and  usually  coexisting  with  single  or  double  hare-lip. 

Causes. — Arrested  development  in  early  fetal  life  from  un- 
known causes.  (Maternal  impression  is  not  a  cause.) 

Symptoms. — Characteristic  deformity;  sometimes  malnutri- 
tion in  infancy  from  difficulty  in  swallowing;  imperfect 
articulation.  • 

Treatment. — Correction  of  the  defect  by  a  plastic  operation. 
In  closing  the  palate  silver-wire  sutures  will  be  used.  After  an 
operation  for  hare-lip  the  narrowing  of  the  breathing  space  to 
which  the  child  has  been  accustomed  may  lead  to  cyanosis  or 
even  asphyxia  if  proper  care  is  not  exercised.  The  nurse  should 
hold  the  lower  lip  down  until  the  child  has  recovered  from  the 
anaesthetic  if  there  is  evidence  that  it  is  not  getting  sufficient  air. 
After  an  operation  for  closure  of  a  cleft  palate  the  patient  must 

377 


378  SUPPLEMENTARY  CHAPTERS 

be  placed  in  a  position  so  that  saliva,  blood,  and  mucus  will  flow 
from  the  mouth.  An  infant  is  held  in  the  lap  of  the  nurse  with 
the  face  down;  an  older  child  is  placed  in  a  semi-sitting  position, 
with  the  face  turned  to  one  side.  Later  the  mouth  may  be 
sprayed  with  a  mild  solution  (e.g.,  dilute  DobelPs)  if  the  child 
does  not  cry  or  struggle,  but  not  otherwise.  Feeding  is  done  with 
a  spoon,  giving  meat  or  chicken  jelly  or  soft  gruels.  Swabs  of 
cotton  or  gauze  must  never  be  used  in  the  mouth,  lest  they  tear 
out  the  wire  sutures. 

Spina  Bifida.  Definition. — A  congenital  cleft  of  the  bony 
arches  of  the  vertebra  in  the  mid-line  of  the  back,  usually  in  the 
lumbar  region,  with  defect  in  varying  degree  of  the  other  tissues 
of  the  back,  resulting  in  a  sacculated  protrusion  of  the  structures 
of  the  spinal  cord  with  its  contained  cerebrospinal  fluid.  The 
child  is  born  with  a  tumor  on  the  back,  hemispherical  in  shape, 
often  about  the  size  of  a  man's  fist,  sometimes  smaller  or  even 
larger.  The  tumor  is  a  sac  containing  fluid,  its  walls  consisting 
of  the  membranes  and  nerve  elements  of  the  spinal  cord,  with 
the  overlying  skin,  and  communicating  with  the  spinal  canal. 
The  skin  may  be  thinned  to  a  parchment-like  metaibrane,  and  is 
frequently  ulcerated  from  chafing  and  pressure. 

Symptoms. — Characteristic  deformity.  Sometimes,  but  not 
always,  weakness  or  paralysis  of  the  legs  and  of  bladder  and 
rectum.  Pressure  on  the  tumor  may  cause  unconsciousness. 

Treatment. — Operative  closure  of  the  defect  when  possible. 
The  prospect  of  success  is  always  very  doubtful.  Nursing  care 
and  constant  vigilance  are  of  the  greatest  importance  to  protect 
the  tumor  from  injury  before  operation  and  from  infection  by 
soiling  with  urine  and  fseces  afterwards.  Spontaneous  rupture 
from  injury  or  ulceration  may  easily  occur,  resulting  in  escape  of 
cerebrospinal  fluid  and  usually  followed  by  fatal  infection.  A 
large  ring  pad  of  gauze  surrounding  the  tumor  may  aid  in  pro- 
tecting it  from  injury. 

Other  Congenital  Defects. — The  most  common,  perhaps,  are 
those  connected  with  the  geni  to -urinary  apparatus  and  with  the 
rectum.  Exstrophy  of  the  bladder,  a  protrusion  of  the  bladder 
wall  through  a  cleft  in  the  anterior  abdominal  wall,  imperforate 
anus,  and  defective  development  of  the  genital  organs  occur. 
These  subjects  are  too  complex  for  discussion  here.  The  surgical 
problems  involved  are  difficult  and  in  many  cases  unsolved. 

Many  varieties  of  congenital  deformities  are  met  with.    The 


SURGICAL  CONDITIONS  379 

most  common  is  club-foot,  with  inversion  of  the  sole  and  torsion 
of  the  whole  foot.  Congenital  dislbcations  of  the  hip  and  other 
joints  also  occur.  These  conditions  come  under  the  care  of  the 
orthopaedic  surgeon.  The  treatment  is  in  part  operative  and  in 
part  by  fixation  and  support  with  proper  apparatus. 

B.  ACQUIRED  DEFECTS  AND  DEFORMITIES 

Many  cases  of  deformity  associated  with  impaired  function 
result  from  paralysis  of  certain  groups  of  muscles  from  injury  or 
disease  of  the  nerves  supplying  them,  the  deformity  being  caused 
by  the  subsequent  contraction  of  the  opposing  group  of  muscles. 
The  most  prolific  cause  of  these  conditions  is  the  disease  known 
as  infantile  paralysis  (anterior  poliomyelitis),  an  infectious 
disease,  caused  by  one  of  the  filterable  organisms,  which  attacks 
young  children  particularly.  The  disease  itself  has  few  and 
slight  symptoms,  as  a  rule,  runs  a  rapid  course,  and  often  passes 
unrecognized.  The  organisms  affect  certain  areas  in  the  spinal 
cord  where  the  motor  nerves  take  their  origin,  and  the  result  is 
paralysis,  sometimes  temporary,  but  often  permanent,  affecting 
a  varying  number  of  groups  of  muscles  throughout  the  body, 
most  commonly  in  the  lower  extremities.  The  treatment  con- 
sists in  exercise  and  stimulation,  when  j)ossil>le,  of  the  affected 
muscles  after  the  acute  disease  has  subsided,  and  in  the  use  of 
suitable  mechanical  supports  to  aid  function  and  prevent  or 
overcome  deformity.  Sometimes  the  tendon  of  an  active 
muscle  can  be  transplanted  so  as  to  make  it  do  the  work  of  a 
paraly/ed  one. 

In  scoliosis  there  is  lateral  curvature  and  often  rotation  of 
the  vertebral  column,  producing  marked  deformity,  due  often  to 
weak  muscles  and  habitual  faulty  position  while  sitting  and 
standing  during  childhood  rather  than  to  any  active  disease. 
The  treatment  is  by  gymnastic  exorcises  and  mechanical  support 
and  correction.  These  cases  belong  preeminently  to  the  domain 
of  the  orthopa'dic  surgeon. 

Rickets  (rhachitis)  is  a  disease  of  childhood  affecting  the 
nutrition  and  growth  of  bone.  Resulting  deformities,  such  as 
bow-legs  and  knock-knee,  are  sometimes  of  such  a  degree  as  to 
interfere  with  locomotion  and  require  operative  means  to  correct 
them. 

A  great  variety  of  deformities  occur  as  the  late  result  of 
injuries  (trauma)  which  have  been  improperly  or  unsuccessfully 


380  SUPPLEMENTARY  CHAPTERS 

treated  at  the  time  of  their  occurrence.  Thus  fractures  may 
unite  with  great  shortening  of  the  limb  due  to  overriding  of  the 
fractured  bones,  or  the  bone  fragments  may  unite  at  an  angle,  or 
they  may  fail  to  unite  at  all .  Joints  may  lose  their  mobility,  becom- 
ing fixed  in  one  position  (ankylosis) ;  soft  parts  may  be  distorted 
by  healing  in  a  wrong  position  or  by  extensive  scarring.  Burns 
by  heat  or  by  acids  or  alkalies  frequently  cause  deformity  through 
the  contraction  of  the  resulting  scar.  The  accidental  swallowing 
of  caustic  substances,  which  happens  with  surprising  frequency 
in  young  children,  results,  when  not  immediately  fatal,  in  stricture 
of  the  oesophagus  from  cicatricial  contraction.  These  conditions 

are  too  numerous  and  varied  to  be  briefly  summarized. 

i 

II.  FOREIGN  BODIES 

When  we  speak  of  a  foreign  body  in  surgery,  we  mean  the 
presence  in  any  of  the  tissues  or  organs  of  the  body  of  any  solid 
inert  substance  that  does  not  belong  there.  Thus,  a  bullet  em- 
bedded in  the  tissues,  or  a  peach-stone  lodged  in  the  O3sophagus, 
or  a  pin  in  the  trachea  is  a  foreign  body;  but  so  also  is  a  loose 
fragment  of  dead  bone  or  a  stone  in  the  kidney  or  bladder, 
substances  in  this  case  not  introduced  from  without,  but  formed 
where  found  as  the  result  of  disease. 

Foreign  bodies  in  the  air-passages  must  always  be  removed. 
Those  in  the  digestive  canal  commonly  pass  without  harm,  but 
sometimes  require  removal.  Foreign  bodies  embedded  in  the 
tissues  frequently  become  encysted  and  remain  harmless  indefi- 
nitely. In  the  presence  of  septic  organisms,  however,  a  foreign 
body  is  apt  to  cause  a  chronic  suppurating  sinus  which  persists 
until  its  removal.  Foreign  bodies  left  in  the  abdominal  cavity 
after  operation  (sponges,  packs,  even  instruments)  deserve 
particular  mention.  This  accident  may  happen  so  easily  that 
every  safeguard  must  be  employed  to  prevent  it.  The  accident 
fortunately  rarely  results  fatally,  but  it  is  very  distressing  for 
the  patient  at  the  best  on  account  of  the  prolonged  morbidity  and 
the  necessity  for  a  second  operation.  It  is,  of  course,  in  the 
highest  degree  humiliating  for  the  surgical  team,  every  member 
of  which  should  bear  the  full  burden  of  the  responsibility.  The 
surgeon  must  know  that  he  has  left  nothing  behind.  The  sponge 
nurse  must  account  for  every  piece  of  gauze  that  has  been  used 
and  the  instrument  nurse  for  every  instrument  before  closure  of 
the  wound. 


SURGICAL  CONDITIONS  381 

III.  TRAUMA 

Definition  and  Causes. — Trauma  means  a  wound  or  injury 
produced  by  external  violence.  The  causes  are,  of  course, 
innumerable,  and  the  injury  may  vary  from  a  mere  scratch  to 
any  degree  of  severity. 

The  Lesions  of  Trauma. — The  essential  thing  in  trauma  is 
what  is  called  a  solution  of  continuity  in  the  tissues;  i.e.,  a  sepa- 
ration as  by  cutting  or  tearing  of  structures  which  are  normally 
united.  So  fine  is  the  network  of  tubes  and  channels  by  means  of 
which  the  cells  of  the  body  are  normally  kept  bathed  in  fluid 
that  even  the  slightest  wound  means  the  rending  of  some  of  these 
blood  or  lymphatic  "  vessels,"  as  they  are  called,  with  a  consequent 
escape  of  fluid  into  the  surrounding  tissues  or  externally,  and 
the  primary  lesions  of  trauma  are  all  associated  with  this  escape 
of  fluid.  If  the  skin  is  divided  there  will  be  external  hemor- 
rhage more  or  less  profuse  and  of  three  varieties.  In  arterial 
hemorrhage  the  blood  is  bright  red  and  escapes  in  forcible, 
intermittent  jets  synchronous  with  the  heart-beats.  In  venous 
hemorrhage  the  blood  is  dark  and  flows  in  a  constant 
stream.  Capillary  hemorrhage  is  seen  as  an  oozing  from  the 
whole  cut  surface.  Capillary  hemorrhage  usually  (except  in 
bleeders)  stops  spontaneously  within  a  few  minutes,  oozing  of  a 
pale  red  or  straw-colored  serum  from  the  wound  surface  continu- 
ing for  many  hours.  If  tissues  are  injured  without  division  of  the 
skin  the  escaping  fluid  gives  rise  to  lesions  varying  according  to 
its  character  and  location.  Ecchymosis  is  the  escape  of  blood  in 
the  deeper  layers  of  the  skin  with  discoloration  (the  familiar 
"black  and  blue"  spots).  A  hcematoma  is  a  mass  of  blood  in  a 
cavity  in  the  tissues  produced  by  trauma,  or  a  circumscribed 
effusion  infiltrating  and  distending  the  spaces  in  the  loose  cellular 
tissue,  particularly  that  under  the  skin.  The  blood  clots  and 
forms  a  swelling  of  varying  size  and  density.  (Edema  is  an  effusion 
of  serous  (watery)  fluid  through  the  walls  of  the  capillaries  into 
the  intercellular  spaces  and  is  often  seen  as  the  result  of  trauma, 
e.g.,  in  sprains.  There  is  a  swelling  which  has  a  dough-like  feel 
to  the  touch,  and  the  skin  over  it  is  paler  than  normal.  Another 
form  of  swelling  known  as  emphysema,  due  to  the  distention  of  the 
tissue  spaces  with  air  or  gas,  is  occasionally  seen  in  wounds  of  the 
lung  and  in  gas  bacillus  infection.  Severe  or  even  fatal  hemor- 
rhage may  occur  into  the  great  serous  cavities  of  the  body  (the 
peritoneal,  pleural,  or  pericardial  cavities)  or  into  the  intestinal 


382  SUPPLEMENTARY  CHAPTERS 

canal  without  escape  of  blood  from  the  body,  and  this  is  known 
as  concealed  hemorrhage.  Abrasions  and  blebs  or  blisters  are 
surface  lesions  familiar  to  every  one. 

Wounds  of  Special  Structures. — Wounds  of  the  skin  and 
subcutaneous  tissue  and  of  the  muscles  are  relatively  insignificant 
(apart  from  hemorrhage  and  infection),  even  when  very  extensive. 
Wounds  of  veins  and  arteries  are  serious  in  proportion  to  their 
size  and  in  accordance  with  the  promptness  with  which  means  of 
checking  hemorrhage  are  applied.  Wounds  of  the  larger  vessels 
are  necessarily  fatal  unless  instant  help  is  given.  Ligation  of  the 
main  blood-vessels  of  a  limb  is,  as  a  rule  (with  some  exceptions), 
followed  by  the  formation  of  a  collateral  circulation  to  supply  the 
part  with  blood.  In  suitable  cases  closure  by  suture  of  a  wound 
in  a  large  blood-vessel  can  be  done  with  restoration  of  the  normal 
blood-channel.  Wounds  of  the  heart  have  been  sutured  with 
recovery  of  the  patient.  A  cut  tendon  results  in  permanent  loss 
of  function  unless  the  divided  ends  are  sutured.  Division  of 
nerve-trunks  results  in  immediate  paralysis  of  the  muscles  whose 
function  they  control  and  in  anaesthesia  of  areas  of  skin  supplied 
by  them.  Nerve-trunks  should  have  their  divided  ends  accurately 
united  by  suture,  this  being  followed  by  restoration  of  function 
after  some  months.  In  wounds  of  the  larger  vital  organs  (brain, 
lungs,  heart,  liver,  kidney)  the  primary  dangers  are  from  hemor- 
rhage, either  from  loss  of  blood  or  (in  the  brain)  from  the 
pressure  by  clots.  In  penetrating  wounds  of  the  serous  cavities, 
including  joints,  and  in  wounds  of  the  hollow  viscera  (stomach, 
intestines,  bladder,  etc.)  the  most  serious  danger  is  from 
infection.  Fractures  are  wounds  of  bone,  usually  with  displace- 
ment and  laceration  of  the  surrounding  soft  parts  and  a  hsematoma 
at  the  seat  of  fracture.  Fractures  are  known  as  simple  when 
the  skin  is  unbroken;  compound  when  the  fracture  communi- 
cates with  an  open  wound;  comminuted  when  there  are  many 
fragments;  and  impacted  when  the  broken  ends  are  wedged 
together.  Simple  fractures  have  no  mortality,  but  always  a 
long  morbidity.  Compound  fractures,  not  infected,  heal  like 
simple  fractures.  If,  however,  infection  takes  place,  the  mor- 
tality is  high  and  the  morbidity  (in  cases  not  fatal)  often  indef- 
initely prolonged.  Tearing  of  the  ligaments  and  of  the  strong 
fibrous  capsule  which  surrounds  a  joint  results  in  displacements 
of  the  bony  structures  which  form  the  joint,  i.e.,  dislocations. 
"Reduction"  or  replacement  of  the  joint  surfaces  in  normal 


SURGICAL  CONDITIONS  383 

position  with  fixation  and  early  passive  motion  of  the  joint 
results  almost  always  in  complete  restoration  of  function.  A  dis- 
location unrecognized  for  weeks  or  months  is  a  very  serious  matter 
for  the  patient.  Reduction  will  be  difficult  (often  impossible 
without  an  open  operation)  and  perfect  restoration  of  function 
dubious.  The  X-ray  should  always  be  used  when  possible  in 
the  diagnosis  of  fractures  and  dislocations. 

Symptoms  and  Signs  of  Trauma. — Obvious  visible  signs, 
laceration  of  tissue,  discoloration  of  the  skin,  local  acute  swell- 
ings, etc.,  need  not  be  further  discussed.  Division  of  tendons  and 
division  or  injury  of  nerves  are  indicated  by  complete  loss  of 
power  either  to  make  movements  of  flexion  or  movements  of 
extension  at  one  or  more  of  the  joints  below  the  seat  of  injury. 
With  nerve  injuries  there  will  often  be  definite  areas  of  insensi- 
bility of  the  skin  as  well.  In  fractures  of  the  upper  arm  (humerus) 
the  power  to  move  the  fingers,  and  the  sensation  on  the  back  of 
the  hand,  should  always  be  tested  at  the  first  inspection  to 
detect  a  possible  nerve  injury.  If  a  main  artery  is  occluded, 
pulsation  will  be  absent  at  the  usual  points  where  it  is  felt  below. 

The  two  most  obvious  signs  of  fracture  are  crepitus  (the 
grating  sensation  conveyed  to  the  finger  by  the  rubbing  together 
of  the  broken  ends  of  the  bone)  and  abnormal  mobility  at  the 
seat  of  fracture.  Where  these  are  absent,  as  in  fractures  near 
joints,  and  in  a  fracture  of  one  bone  only  of  the  forearm  or  leg, 
special  points  of  tenderness  on  pressure  on  the  shaft  of  one  bone 
or  near  the  joint  suggest  a  strong  suspicion  of  fracture.  Disloca- 
tion is  always  to  be  suspected  where  there  is  abnormal  fixation  of 
a  joint  with  more  or  less  deformity. 

Symptoms  of  Trauma  in  Special  Regions. — In  injuries  of  the 
head  the  most  important  point  to  be  determined  will  be  whether 
there  is  a  depressed  fracture  or  hemorrhage  within  the  skull 
causing  pressure  on  the  brain.  Paralysis  of  the  arm  on  the  side 
opposite  to  the  injury  is  a  positive  sign  of  pressure  in  certain 
areas  of  the  brain.  Bleeding  and,  later,  a  serous  discharge  from 
the  car  indicate  fracture  at  the  base  of  the  skull.  In  other  cases, 
persistent  headache,  mental  dulness,  and  an  abnormally  slow 
pulse  are  suggestive  of  pressure.  Characteristic  changes  in  the 
retina  soon  appear  in  cases  of  intracranial  pressure,  which  can  be 
recognized  by  an  examination  with  the  ophthalmoscope,  which 
must,  of  course,  always  be  made  by  a  specialist. 

In  injuries  of  the  thorax,  fracture  of  ribs  will  be  indicated  by 


384  SUPPLEMENTARY  CHAPTERS 

sharp  pain  in  the  act  of  breathing;  wounds  of  the  pleura  by 
sputtering  of  air  in  the  wound ;  wounds  of  the  lung  by  the  coughing 
up  of  blood.  Abdominal  injuries  are  very  varied.  The  most 
serious  are  wounds  of  large  vessels  leading  to  concealed  hemor- 
rhage, and  wounds  or  ruptures  of  hollow  viscera  with  escape  of 
their  contents,  resulting  in  peritonitis.  The  symptoms  of  these 
conditions  are  given  elsewhere  (Chapter  XVII).  In  crushing 
injuries  of  the  lower  abdomen  or  pelvis,  blood  in  the  urine  should 
be  looked  for.  If  voiding  of  urine  is  delayed  the  surgeon  should  be 
informed  before  catheterization  is  attempted,  since  if  a  rupture 
of  the  bladder  is  present  an  immediate  operation  will  be  necessary. 

General  Principles  in  the  Treatment  of  Trauma. — The  pri- 
mary indications  which  the  surgeon  will  endeavor  to  meet  in  the 
treatment  of  an  injury  will  be  arrest  of  hemorrhage,  if  present; 
prevention  of  infection,  if  there  is  an  open  wound ;  restoration  of 
the  displaced  tissues  and  structures  to  their  normal  relation  so  far 
as  possible,  and  fixation  of  the  injured  part  when  this  can  be  done. 
The  great  therapeutic  agent  in  the  treatment  of  trauma  is  rest, 
i.e.,  prevention  of  movement  and  prevention  of  the  exercise  of 
function.  Later,  restoration  of  function,  particularly  of  the* 
joints  involved,  must  be  aided  by  passive  and  active  exercise, 
which  should  be  begun  as  soon  as  the  healing  process  has  advanced 
so  far  that  it  will  not  be  hindered  by  these  procedures.  In  the 
case  of  an  injured  limb,  elevation  is  important  to  aid  the  return 
circulation,  and  all  tension  should  be  avoided  either  by  stitches 
or  bandages.  Water  should  be  given  freely  after  injury.  The 
treatment  of  shock  from  trauma  has  been  discussed  elsewhere. 

The  capacity  of  the  human  body  to  endure  and  to  recover 
from  trauma  is  amazing.  If  hemorrhage  and  sepsis  can  be  con- 
trolled, recovery  may,  and  often  does,  take  place  from  the  most 
appalling  lacerations  and  dismemberments. 

Burns, — The  nature  and  varieties  of  burns  have  already  been 
described  (page  63).  The  best  treatment  is  that  by  paraffin 
occlusion  (page  149).  Boric  ointment  has  been  much  used. 
Dichloramine-T,  in  oily  solution  is  a  useful  application.  A  roller 
bandage  should  not  be  used  to  fix  the  dressing,  as  a  rule.  It  is 
wasteful  of  material  and  time.  Instead,  a  swathe  made  of  muslin, 
or  even  a  towel,  should  be  pinned  neatly  about  the  part  to  hold 
the  dressing  in  place.  A  few  spiral  turns  of  a  roller  may  be  added 
if  necessary  for  security,  and  strips  of  adhesive  added  to  prevent 
slipping.  Such  a  dressing  is  easily  and  quickly  removed  with 


SURGICAL  CONDITIONS  385 

very  little  disturbance  of  the  patient.  In  the  dry  treatment  of 
burns  no  dressing  is  applied.  The  burn  is  exposed  to  the  air  pro- 
tected from  flies  by  a  layer  of  gauze  over  a  cradle. 

Bed  Sores.  Definition. — Necrosis  of  the  skin,  from  prolonged 
pressure-trauma,  at  the  points  which  bear  the  weight  of  the  body 
in  recumbency. 

Causes. — Low  vitality  of  the  skin  involved,  from  prolonged  ill- 
ness, or  from  lesions  of  the  nerve  supplying  the  area ;  and  weakness 
or  paralysis  which  prevents  the  patient  from  shifting  his  position. 

Symptoms. — Dark  discoloration  of  the  skin,  followed  later  by 
the  formation  of  blebs,  and  finally  by  sloughing  ulcers. 

Treatment. — In  cases  of  prolonged  illness,  and  particularly 
in  cases  with  paralysis  from  spinal  injury,  the  back  should  be  fre- 
quently inspected,  especially  over  the  bony  prominences.  The 
sheets  should  be  kept  free  from  wrinkles  and  dry.  The  skin  at  the 
points  of  pressure  should  be  bathed  several  times  daily  with 
alcohol  and  powdered  freely.  The  position  of  the  patient  should 
be  shifted  often  to  relieve  alternately  points  of  pressure.  In  a 
spinal  injury  case  an  air  or  water  bed,  which  distributes  the 
pressure  evenly  is  almost  essential.  When  discoloration  appears 
a  ring  pad  should  encircle  the  area.  Oxide  of  zinc  ointment 
spread  on  lint  is  the  usual  dressing.  Paraffin  (page  149)  serves 
even  better. 

IV.  SURGICAL  INFECTIONS 

The  Septic  Diseases. — Sepsis  in  wounds  and  the  general 
symptoms  of  infection  have  been  discussed  in  previous  sections. 
Brief  reference  will  be  made  here  to  some  of  the  most  common 
forms  of  septic  disease. 

(1)  Erysipelas  is  an  acute  disease  affecting  the  skin,  due  to 
infection  with  the  streptococcus ;  characterized  by  fever,  chill,  and 
intense  local  redness  of  the  skin,  with  cedema,  the  eruption  tend- 
ing to  spread  rapidly,  and  being  accompanied  with  sensations 
of  itching  and  burning.  Idiopathic  erysipelas,  usually  affecting  the 
face,  principally,  has  a  low  mortality.    Erysipelas  complicating 
wounds  is  frequently  fatal.    There  is  no  standardized  treatment. 
The  use  of  antistreptococcic  serum  has  been  disappointing. 

(2)  Diffuse  Cellulitis  or  Phlegmon. — This  disease  is  a. septic 
infection   involving   the   subcutaneous   cellular   tissues.      It   is 
characterized  by  great  swelling  from  infiltration,  cedematous  or 
semi-purulent   in   character,   tends  to   spread   rapidly,   and   is 

25 


386  SUPPLEMENTARY  CHAPTERS 

associated  with  severe  constitutional  symptoms.  The  primary 
infecting  agent  is  usually  the  streptococcus,  but  the  Staphyl- 
ococcus  pyogenes  also  plays  an  important  part  as  a  secondary 
infection.  Red  streaks  upon  the  skin  running  toward  the  trunk 
indicate  involvement  of  the  lymph-vessels.  The  hand  and  arm 
are  frequently  the  seat  of  the  infection,  particularly  among  men 
who  do  rough  and  dirty  work  with  their  hands.  The  skin  is 
often  undermined  with  pus  over  large  areas  in  the  later  stages. 
Sloughing  of  subcutaneous  tissues  including  tendon  sheaths  may 
occur,  causing  serious  disability  after  the  inflammation  has  sub- 
sided. The  treatment  is  by  numerous  free  incisions,  moist  heat, 
either  in  the  form  of  wet  dressings  or,  better,  the  continuous  bath. 
In  this  and  in  all  other  forms  of  septic  infection  the  one  most 
important  medicine  for  internal  administration  is  water.  It  is 
not  enough  to  give  the  patient  water  when  he  calls  for  it.  The 
nurse  should  see  that  the  patient  drinks  a  glass  of  water,  or  as 
much  as  he  will,  at  least  every  hour. 

(3)  Abscess  is  a  collection  of  pus  in  a  cavity  which  has  formed 
in  some  locality  in  the  body  as  a  result  of  necrosis  of  tissue-cells 
and  liquefaction  of  the  dead  cell-bodies,  due  to  the  action  of 
pyogenic  bacteria  which  have  invaded  the  tissues  at  this  point. 
The  staphylococcus  is  by  far  the  most  common  offender.     The 
pus  itself  is  composed  of  myriads  of   leucocytes,   which   have 
migrated  into  the  region  in  their  role  of  defenders  against  infec- 
tion.   In  a  superficial  abscess,  the  local  symptoms  will  be  swelling, 
redness,   heat,   fluctuation,  or  the  sensation   conveyed  to  the 
examining  fingers  as  of  fluid  under  the  skin,   and  pain  with 
tenderness  on  pressure.    In  deep  abscesses,  all  these,  except  pain 
and  tenderness  (and  even  these  at  times),  may  be  absent.    The 
constitutional  symptoms  of  sepsis  will  always  be  present.     The 
treatment  is  incision  for  the  purpose  of  drainage.     During  the 
acute  inflammatory  stage,  before  the  abscess  has  fully  formed, 
hot  fomentations  will  hasten  the  process  and  add  to  the  patient's 
comfort.    Antiseptics  are  a  useless  addition  to  the  fomentations. 
The  drains  used  may  be  of  rubber  tubing  or  wicks  of  gauze. 
Irrigation  of  the  abscess  cavity  is  of  doubtful  utility  in  most 
cases.     Drainage  should  be  established  as  early  as  possible  in 
order  to  arrest  the  process.     Recovery  without  incident  is  the 
rule  when  this  has  been  done. 

(4)  Osteomyelitis  is   a  septic   inflammation   in   bone.     The 
staphylococcus  is  here  also  the  most  common  cause,  although  the 


SURGICAL  CONDITIONS  387 

streptococcus,  and  occasionally  the  typhoid  bacillus,  may  become 
invaders.  The  way  of  access  for  the  invaders  is  by  the  blood 
stream,  except  in  compound  fractures.  There  is  often  a  history 
of  some  previous  injury  in  the  region  infected.  The  disease  is 
more  common  in  early  life.  The  process  of  disease  is  essentially 
the  same  as  in  abscess  formation  in  the  soft  tissues,  differing  only 
because  of  the  character  of  the  tissue  invaded.  Necrosis  in  bone 
results  in  the  formation  of  large  detached  pieces  of  dead  bone, 
which  may  be  discharged  later  or  be  removed  at  operation.  The 
long  bones  of  the  lower  extremity  are  the  ones  most  commonly 
affected.  The  disease  may  have  a  very  acute  onset,  but  is  often 
very  chronic  in  its  development,  lasting  for  years.  Later  local 
abscesses  and  sinuses  appear  with  constant  discharge  of  pus  and 
occasionally  pieces  of  dead  bone.  The  symptoms  are  local  pain, 
frequently  very  severe,  sometimes  worse  at  night.  There  is 
usually  local  tenderness,  and  redness  and  swelling  may  be  present. 
Constitutional  symptoms  are  always  present  and  may  be  mild 
or  very  severe.  The  treatment  is  operative. 

(5)  Sepsis  in  Serous  Cavities. — Sepsis  of  the  large  joint 
cavities  is  always  a  serious  matter.  The  local  and  constitutional 
reactions  are  usually  very  severe.  The  suffering  is  acute  and 
prolonged  and  the  result  disastrous  to  the  joint  itself  or  even 
fatal  to  the  patient.  The  symptoms  are  local  swelling  and  pain 
(usually  with  a  history  of  an  open  wound  of  the  joint)  and  the 
constitutional  symptoms  of  sepsis.  Prompt  operative  treatment 
is  required.  Sepsis  in  the  abdomen  (peritonitis)  is  considered  in 
another  section.  Sepsis  in  the  pleural  cavity  is  known  as  empy- 
ema.  It  occurs  most  commonly  following  an  attack  of  pneumonia, 
being  caused  in  this  case  by  the  same  organism  (the  pneumo- 
coccus).  The  diagnosis  is  determined  by  the  physical  signs  and  the 
aspirating  needle.  The  treatment  is  evacuation  of  the  pus 
through  an  operative  opening,  usually  with  resection  of  a  portion 
of  a  rib.  Recovery  is  the  rule.  An  important  feature  of  the 
after-treatment  is  some  form  of  respiratory  exercise  to  expand  the 
lung,  as  by  blowing  water  through  suitably-arranged  tubes  from 
one  bottle  to  another. 

2.  Tuberculosis. — This  disease,  one  of  the  most  common  to 
which  man  is  subject,  is  caused  by  the  invasion  of  the  bacillus 
tuberculosis.  It  is  sometimes  acute,  but  usually  runs  a  chronic 
course;  may  attack  almost  any  tissue  in  the  body;  and  gives  rise 
to  a  very  great  variety  of  conditions  of  disease.  The  lesions 


388  SUPPLEMENTARY  CHAPTERS 

produced  by  the  organism  are  of  the  same  kind  in  a  general  way 
as  those  produced  by  other  organisms;  i.e.,  there  is  local  death 
of  some  cells,  with  reproduction  and  increase  of  other  cells  in  an 
attempt  of  the  body  toward  defence  and  repair.  In  minor  ways 
the  lesions  are  different  from  those  produced  by  other  organisms, 
so  that  they  can  be  recognized.  The  typical  lesion  known  as  a 
tubercle  is  a  minute,  grayish-white  nodule  which  can  be  seen  by 
the  naked  eye  in  cases  of  tuberculous  peritonitis  when  the  abdo- 
men is  opened.  In  larger  masses,  necrosis  appears  in  a  form 
known  as  caseation,  from  its  cheese-like  appearance.  The 
principal  forms  of  surgical  tuberculosis  are  those  affecting  the 
lymphatic  glands  and  the  bones  and  joints.  Large  tumors  of  the 
neck  are  common  from  infection  of  the  numerous  lymphatic 
glands  in  this  region  with  this  organism.  Very  extensive  opera- 
tions are  frequently  done  for  their  removal.  Tuberculous  disease 
of  bones  and  joints  results  in  slow  disintegration  of  the  structures 
affected,  giving  rise  to  distressing  deformities.  The  treatment  of 
these  conditions  is  preeminently  not  an  active  treatment,  except 
when  the  destruction  of  tissue  is  hopelessly  far  advanced.  It  is 
found  that,  if  motion  can  be  prevented  and  the  pressure  from 
gravity  and  from  muscular  contraction  can  be  removed  from  the 
diseased  bones,  recovery  will  often  take  place  without  other  aid. 
Prolonged  fixation  of  the  diseased  area  by  means  of  suitable 
apparatus  is  the  most  important  means  of  treatment  employed. 

V.  TUMORS  (NEW-GROWTHS,  NEOPLASMS) 

Tumors  may  be  defined  as  new-growths  of  tissue  occurring 
in  an  organism,  which  do  not  themselves  perform  any  function 
and  which  tend  by  their  presence  or  by  their  growth  to  injure  or 
destroy  the  organism.  They  may  be  broadly  classified,  according 
to  their  terminal  effects  upon  the  organism,  as:  (1)  benign  and 
(2)  malignant.  According  to  tissue  characteristics,  they  may  be 
further  classified  as :  (1)  osteoma;  (2)  myoma;  (3)  fibroma;  (4)  li- 
poma;  (5)  cystoma;  (6)  epithelioma;  (7)  endothelioma  (the  first  five 
of  which  are  benign  and  the  last  two  either  benign  or  malignant) ; 
(8)  carcinoma,  and  (9)  sarcoma,  both  of  which  are  malignant. 

Causes. — The  causes  of  the  appearance  of  the  various  new- 
growths  are  not  understood. 

Symptoms. — The  general  and  invariable  symptom  is  the 
appearance  of  an  abnormal  growing  mass  in  any  of  the  tissues  or 
organs  of  the  body.  According  to  the  type  of  neoplasm  and  its 


SURGICAL  CONDITIONS  389 

location  and  manner  of  growth,  there  may  be  varying  local  and 
general  manifestations  of  its  presence. 

Treatment. — The  treatment,  in  general,  consists  in  operative 
removal  of  the  growth.  Slow-growing  or  stationary  benign 
tumors,  which  do  not  interfere  with  the  functions  of  the  organism 
and  have  no  tendency  to  malignant  degeneration,  may  be  per- 
mitted to  remain.  In  certain  of  the  new-growths,  as  epithelioma 
of  the  lip  or  face  and  fibroma  of  the  uterus,  treatment  by  the 
Rontgen  ray  and  radium  may  offer  advantages  over  operative 
interference. 

VI.  OTHER  ORGANIC  DISEASES 

1.  Goitre  (Struma).  Definition. — A  goitre  is  any  abnormal 
enlargement  of  the  thyroid  gland  that  is  not  due  to  one  of  the 
benign  or  malignant  new-growths.  Goitres  may  be  broadly 
classified  as:  (1)  simple  and  (2)  exophthalmic. 

Causes. — The  causes  of  goitre  are  not  clearly  understood.  In 
the  simple  form  there  is  a  probability  of  some  water-borne  irritant 
being  an  excitant  factor.  The  exophthalmic  type  is  associated  with 
a  faulty  functioning  of  the  thyroid  gland,the  cause  being  unknown. 

Symptoms. — The  characteristic  symptom  common  to  both 
forms  of  goitre  is  the  typical  enlargement  of  the  thyroid  gland. 
This  is  frequently  the  only  symptom  in  the  simple  type;  but  in 
exophthalmic  goitre  we  have:  (1)  tachycardia;  (2)  nervous 
phenomena;  (3)  exophthalmos,  and  (4)  more  or  less  general 
emaciation. 

Treatment. — The  treatment  is  operative,  consisting  in  the 
removal  of  such  portions  of  the  thyroid  gland  as  may  seem 
necessary  to  the  surgeon. 

2*  Gangrene  (Mortification).  Definition. — Gangrene  is  a 
condition  characterized  by  the  death,  in  mass,  of  body  tissues. 
It  may  be  classified  as:  (1)  moist  and  (2)  dry. 

Causes. — The  cause  of  gangrene  may  be  anything  that  com- 
pletely destroys  the  circulation  of  a  part  or  interferes  with  it 
sufficiently  to  prevent  proper  nourishment. 

Symptoms. — In  the  moist  variety  the  skin  is  frequently  pale 
and  cold  at  first,  assuming  a  mottled  appearance  later — either 
purplish  or  greenish  black.  There  occur:  (1)  softening  of  the 
mass;  (2)  the  formation  of  blisters;  (3)  an  offensive  odor,  and  (4) 
the  constitutional  symptoms  of  sepsis.  In  the  dry  form  there  is 
a  gradual  drying  and  blackish  discoloration  of  the  part,  accom- 


390  SUPPLEMENTARY  CHAPTERS 

panied  by  the  loss  of  sensation  and  the  formation  of  a  definite 
line  of  demarcation  between  the  gangrenous  and  healthy  tissues. 
Constitutional  symptoms  are  not  so  common  as  in  the  moist  form. 

Treatment. — The  treatment  is  operative,  consisting  in  excision 
(or  amputation  in  the  case  of  extremities),  extending  well  into 
tissue  having  an  ample  blood  supply. 

3.  Aneurism.  Definition. — An  aneurism  is  a  sacculated  or 
fusiform  tumor  directly  associated  with  the  lumen  of  a  blood- 
vessel and  having  for  its  walls  those  of  the  vessel. 

Causes. — Aneurisms  may  be  congenital  or  result  from  disease 
of  or  injury  to  the  vessel  walls. 

Symptoms. — The  invariable  symptom  is  the  development  of  a 
soft,  pulsating  mass  along  the  course  of  a  large  vessel.  This, 
depending  upon  its  location,  may  give  rise  to  varying  symptoms 
resulting  from  circulatory  or  pressure  disturbance. 

Treatment. — The  medical  treatment  consists  in  rest  and 
special  medicinal,  dietetic,  and  hygienic  measures.  The  surgical 
treatment,  which  is  particularly  adapted  to  the  treatment  of 
external  (superficial)  aneurisms,  consists,  where  possible,  in  an 
operative  restoration  of  the  parts  to  normal.  In  other  cases, 
complete  occlusion,  by  ligature,  of  the  affected  vessel  may  be 
necessary. 

VII.  ABDOMINAL  CONDITIONS 

1 .  Ulcer  of  Stomach  or  Duodenum.  Definition. — Ulcers  of  the 
stomach  or  duodenum  are,  as  the  names  would  indicate,  solutions 
in  the  continuity  of  the  mucous  lining  of  the  stomach  or  the 
duodenum. 

Causes. — They  probably  follow  interference  with  the  blood 
supply  of  the  part.  Gastric  ulcer  is  more  common  in  females  of 
early  adult  life;  duodenal  in  males  between  the  ages  of  twenty 
and  forty  years.  Both  types  are  probably  influenced  by  the 
hyperacidity  commonly  accompanying  them. 

Symptoms. — Symptoms  are  frequently  absent  in  gastric  and 
duodenal  ulcer  until  the  appearance  of  hemorrhage  from  either 
the  stomach  or  bowels  or  the  evidences  of  perforation.  The 
usual  symptoms  are:  (1)  pain  immediately  following  the  ingestion 
of  food  in  gastric  ulcer,  or  one  or  more  hours  later  in  the  duodenal 
type;  (2)  hemorrhage,  and  (3)  dyspeptic  symptoms,  accompanied 
by  nausea  and  vomiting. 

Treatment. — The  first  treatment  may  consist   of  diet   and 


SURGICAL  CONDITIONS  391 

absolute  rest  over  an  extended  period.  Where  this  fails,  the 
treatment  is  operative — a  gastro-enterostomy  being  performed 
or  the  ulcer  excised. 

Special  Nursing  Point. — Close  watch  should  be  kept  for 
evidences  of  concealed  hemorrhage  after  the  performance  of 
gastro-enterostomy. 

2.  Carcinoma  of  the   Stomach  or  Intestine.     Definition. — 
Carcinoma  of  the  stomach  or  intestine  is  a  malignant  new-growth 
originating  in  the  epithelial  elements  of  these  organs. 

Causes. — The  predisposing  causes  may  be  indicated,  in  the 
order  of  their  importance,  as:  (1)  age,  about  97  per  cent,  occurring 
after  the  thirtieth  year;  (2)  heredity,  about  15  per  cent,  of  gastric 
carcinoma  giving  a  family  history  of  carcinoma;  and  (3)  previous 
ulceration  or  chronic  inflammation.  The  immediate  cause  is 
not  known. 

Symptoms. — The  usual  symptoms  are  pain,  digestive  dis- 
turbances, vomiting,  anaemia,  and  progressive  loss  of  weight 
occurring  in  an  individual  after  the  thirtieth  year.  Progressive 
chronic  intestinal  obstruction  is  usually  present  in  the  intestinal 
form,  and,  during  the  advanced  stages  of  both  types,  an  abdom- 
inal mass  is  generally  demonstrable. 

Treatment. — The  curative  treatment  depends  upon  an  early 
diagnosis  and  radical  operative  removal  of  the  entire  growth. 
The  palliative  treatment  consists  in  such  measures  as  may  add 
most  to  the  support  and  comfort  of  the  patient.  In  addition  to 
diet  and  opiates,  surgical  intervention  may  be  indicated  to  relieve 
symptoms  of  obstruction. 

3.  Appendicitis,    Intestinal    Perforation,    and    Suppurative 
Peritonitis.    Definitions. — Appendicitis  is  an  inflammation  of  the 
vermiform  appendix.     It  may  be  classified  as:  (1)  catarrhal,  (2) 
ulcerative,  and  (3)  gangrenous.    Either  of  the  latter  forms  may 
progress  to  perforation  and  consequent  suppurative  peritonitis. 

Intestinal  perforation  is  a  perforation  of  all  the  walls  of  any 
portion  of  the  intestinal  canal. 

Suppurative  peritonitis  is  an  inflammation  of  the  peritoneum 
resulting  from  invasion  by  one  or  more  species  of  the  pyogenic 
microorganisms  and  accompanied  by  pus  formation.  It  may  be 
either  circumscribed  or  diffuse. 

Causes. — Appendicitis  is  a  disease  of  both  sexes,  being  some- 
what more  frequent  in  the  male;  occurring  chiefly  in  early  adult 
and  middle  life,  and  depending  to  some  extent  upon  heredity  and 


392  SUPPLEMENTARY  CHAPTERS 

diet.  The  principal  causes  of  its  occurrence  are,  however,  the 
presence  of  anatomical  defects,  foreign  bodies,  and  pathogenic 
microorganisms. 

Intestinal  perforation  is  usually  a  result  of  inflammation, 
ulceration,  or  injury.  Its  most  common  single  cause  is  one  of  the 
forms  of  perforative  appendicitis. 

Suppurative  peritonitis  is  caused  by  the  introduction  of  one  or 
more  species  of  the  pyogenic  microorganisms  into  the  peritoneal 
cavity.  This  may  be  the  result,  among  other  causes,  of  a  perforat- 
ing gastric  or  intestinal  ulcer;  a  perforating  or  rupturing  appen- 
dicitis; or  the  leakage  or  rupture  of  a  pyosalpinx. 

Symptoms. — The  symptoms  of  appendicitis,  in  the  order  of 
their  occurrence,  are:  (1)  abdominal  pain,  usually  epigastric  in 
location;  (2)  nausea  or  vomiting;  (3)  general  abdominal  tender- 
ness, with  point  of  maximum  intensity  in  right  lower  quadrant, 
and  (4)  fever. 

The  symptoms  of  intestinal  perforation  may  be  very  indefinite, 
particularly  as  this  condition  is  merely  a  sequel  to  a  preexistent 
pathological  process.  Rupture,  or  perforation,  of  the  appendix 
may  be  followed  by  immediate  diminution  or  cessation  of  the 
existent  symptoms,  but  later  gives  rise  to  those  of  a  circumscribed 
or  diffuse  suppurative  peritonitis.  Where  the  perforation  occurs 
at  the  site  of  an  ulcer  elsewhere  in  the  intestinal  tract  the  symp- 
toms are:  (1)  sudden,  violent  pain;  (2)  abdominal  muscular 
rigidity;  (3)  nausea  or  vomiting,  and  (4)  elevation  of  temperature. 
The  last  two  symptoms  are  those  introducing  the  suppurative 
peritonitis  and  will  be  followed,  if  the  peritonitis  is  diffuse,  by  (5) 
abdominal  distention  and,  if  circumscribed,  by  (6)  the  presence 
of  a  palpable  abscess  mass. 

Treatment. — The  treatment  of  these  conditions  is  operative, 
consisting  in  removal  of  the  appendix,  where  acute  catarrhal 
appendicitis  exists;  in  suturing  of  the  perforation  and  drainage 
or  removal  of  the  primary  diseased  organ,  and  drainage  in  the 
other  conditions. 

Special  Nursing  Points. — After  operation  for  any  acute  sup- 
purative process  in  the  abdominal  cavity,  close  watch  should  be 
kept  for  the  early  symptoms  of  intestinal  obstruction.  When 
nursing  any  patient  where  intestinal  perforation  may  occur  (as 
gastric  or  duodenal  ulcer,  typhoid  fever,  or  appendicitis),  the 
occurrence  of  sudden  abdominal  pain  should  suggest  the  imme- 
diate summoning  of  the  attending  physician. 


SURGICAL  CONDITIONS  393 

4.  Intestinal  Obstruction  (Ileus).    Definition. — Intestinal  ob- 
struction is  that  condition  in  which,  from  any  of  several  causes, 
the  intestinal  contents  cannot  pass  through  that  part  of  the 
alimentary  tract  situated  between  the  pylorus  and  the  anus. 

Causes. — Intestinal  obstruction  may  be  due  to:  (1)  bands  or 
adhesions;  (2)  intussusception,  the  invagination  of  one  portion 
of  the  gut  into  an  immediately  adjoining  section;  (3)  volvulus, 
twisting  of  the  intestine  and  mesentery;  (4)  thrombosis  of  the 
mesenteric  artery,  or  (5)  adynamic  ileus,  a  paralysis  of  the 
muscular  coats  of  the  bowel. 

Symptoms. — The  symptoms  of  intestinal  obstruction  are:  (1) 
absence  of  bowel  movements  or  the  passage  of  flatus;  (2)  nausea, 
followed  by  vomiting,  which  becomes  persistent  and  may,  during 
the  later  stages,  contain  fecal  matter;  (3)  abdominal  pain;  (4) 
abdominal  distention;  (5)  visible  peristalsis;  (6)  rapid  pulse;  (7) 
thoracic  type  of  breathing;  and  (8)  elevated  temperature  in  the 
form  due  to  thrombosis  of  the  mesenteric  artery,  but  normal  or 
subnormal  temperature  in  the  other  forms.  In  intussusception 
a  sausage-shaped  mass  may  sometimes  be  palpated. 

Treatment. — The  treatment  is  operative  and  varies  with  the 
immediate  cause.  An  early  diagnosis  is  of  vital  importance. 

5.  Tuberculous  Peritonitis.     Definition. — Tuberculous  peri- 
tonitis is  an  inflammation  of  the  peritoneum,  characterized  by 
the  formation  of  numerous  tubercles. 

Cause. — The  immediate  cause  is  the  invasion  of  the  peritoneum 
by  the  tubercle  bacillus. 

Symptoms. — The  symptoms  are  vague.  In  a  typical  case  they 
would  be  somewhat  as  follows:  (1)  digestive  disturbances;  (2) 
abdominal  discomfort,  at  times  amounting  to  pain;  (3)  progres- 
sive general  loss  of  weight;  (4)  abdominal  enlargement  due  to 
free  or  encysted  fluid,  and  (5)  irregular  temperature  elevation. 

Treatment. — The  operative  treatment  consists  solely  in  open- 
ing the  abdomen  and  evacuating  the  fluid.  All  other  treatment 
is  dietetic  and  hygienic. 

6.  Hernia  (Rupture).    Definition. — A  hernia,  in  the  sense  here 
used,  may  be  defined  as  any  protrusion  of  an  abdominal  viscus 
through  a  normal  or  abnormal  opening. 

Causes. — Among  the  predisposing  causes  to  hernia,  age,  sex, 
and  heredity  all  play  important  parts.  The  exciting  cause  may 
be  anything  that  increases  intra-abdominal  pressure,  as  sneezing, 
coughing,  lifting  heavy  bodies,  or  even  straining  at  stool. 


394  SUPPLEMENTARY  CHAPTERS 

Symptoms. — The  only  symptom  of  a  simple,  reducible  hernia 
is  the  presence  of  a  soft  tumor  at  one  of  the  normal  abdominal 
openings  (femoral,  inguinal,  or  umbilical).  There  may  be  some 
soreness  in  the  mass.  If  the  mass  gives  a  definite  impulse  on 
coughing  and  is  easily  reducible,  it  is  almost  certainly  a  hernia. 
Strangulated  hernia,  in  addition  to  the  local  symptoms  mentioned 
above,  gives  the  symptoms  of  intestinal  obstruction. 

Treatment. — In  the  simple,  reducible  form  the  hernia  may  be 
treated  by  the  application  of  a  suitable  truss.  Always  in  the 
irreducible  and  strangulated  forms,  and  preferably  in  the  simple 
form,  the  treatment  should  consist  in  an  operative  restoration 
of  the  parts  to  normal.  In  the  advanced  strangulated  form 
intestinal  resection  may  be  necessary. 

7.  Gall=stone  Disease  (Cholelithiasis).  Definition. — Gall- 
stone disease  is  a  condition  of  the  gall-bladder  characterized  by 
the  formation  of  one  or  more  concretions  within  its  cavity. 

Causes. — The  primary  cause  is  probably  bacterial  infection, 
although  obstruction  to  free  drainage  and  the  so-called  gall-stone 
diathesis  may  play  an  important  contributing  role. 

Symptoms. — The  symptoms  are:  (1)  history  of  long-continued 
digestive  disturbance  and  probably  one  or  more  attacks  of  colic; 
(2)  sudden  onset  of  violent  colic-like  pain,  which  usually  subsides 
in  from  a  few  minutes  to  several  hours;  and  (3)  vomiting.  In  the 
obstructive  form  (common  duct  stone),  (4)  jaundice,  (5)  clay- 
colored  stools,  and  (6)  fever  are  usually  added  to  the  preceding 
symptoms.  The  pain  in  gall-stone  disease  is  frequently  referred 
backward  and  upward  towards  the  right  shoulder  or  scapula. 

Treatment. — The  treatment  is  operative,  consisting  in  ex- 
cision of  the  gall-bladder  with  the  containing  stones  (cholecys- 
tectomy)  or  in  the  removal  of  the  stones  and  drainage  of  the 
gall-bladder  (cholecystotomy) . 

Special  Nursing  Points. — After  all  operations  on  the  bile- 
passages,  careful  notes  should  be  kept  regarding  the  character  and 
amount  of  drainage  and  the  character  and  color  of  stools. 

VIII.  EPITOME  OF  GYNAECOLOGICAL  DISEASES 
The  diseased  conditions  encountered  in  the  care  of  gynaeco- 
logical patients  may  be  broadly  divided  into  four  classes:  (1)  mal- 
formations and  displacements;  (2)  injuries;  (3)  inflammations, 
and  (4)  new-growths. 


GYNAECOLOGICAL  CONDITIONS  395 


1.  MALFORMATIONS  AND  DISPLACEMENTS 

1.  Atresia  or  Stenosis  of  the  Vagina.    Definitions. — Atresia 
is  the  absence  or  closure  of  the  normal  opening.     Stenosis  is  a 
narrowing  of  the  normal  opening. 

Causes. — Atresia  may  be  due  to  a  congenitally  imperf orate 
hymen  or  to  a  later  adhesion  of  the  vaginal  walls,  following  injury 
or  inflammatory  process.  Stenosis  may  be  congenital  or  may 
result  from  the  contraction  of  scar  tissue  following  injury  or 
inflammation. 

Symptoms. — The  symptoms  of  atresia  would  be,  in  the  order 
of  their  appearance,  amenorrhoea,  uterine  colic  of  a  progressive 
severity  as  the  successive  'menses  are  dammed  back,  and,  finally, 
the  possible  occurrence  of  reflex  convulsive  seizures.  Stenosis 
would  probably  give  no  early  symptoms,  but  would  be  a  subse- 
quent cause  of  dyspareunia. 

Treatment. — The  treatment  would  consist,  in  either  case,  of 
an  operative  restoration  of  the  parts  to  normal,  the  operative 
procedure  varying  extensively  with  the  location,  extent,  and 
cause  of  the  condition  in  each  particular  case. 

2.  Anteflexion  of  the  Uterine  Cervix.   Definition. — Anteflexion 
of  the  cervix  is  an  acute  bending  forward  of  the  uterine  cervix,  the 
body  of  the  uterus  maintaining  its  normal  anterior  position. 

Cause. — Anteflexion  of  the  cervix  is  congenital  in  origin. 

Symptoms. — Where  any  symptoms  exist,  they  are  those  of  an 
obstructive  dysmenorrhcea;  namely,  uterine  colic  preceding  full 
establishment  of  flow;  frequently  clotting  of  the  early  flow;  not 
infrequently  sacral  or  lumbosacral  intramenstrual  pain,  and 
occasionally  pain  in  the  region  of  the  uterine  appendages.  There 
is  generally  a  slight  leucorrhoeal  discharge. 

Treatment. — The  treatment  is  operative,  varying  from  a 
simple  dilatation  and  curettage  to  more  extensive  plastic  opera- 
tions designed  to  straighten  the  uterine  canal  by  shortening  the 
posterior  cervical  wall. 

3.  Retroversion  of  the  Uterus.    Definition. — Retroversion  of 
the  uterus  is  a  swinging  backward  of  the  uterine  body  towards 
the  pouch  of  Douglas,  the  uterine  cervix  at  the  same  time  swinging 
forward  towards  the  anterior  vaginal  vault. 

Causes. — Retroversion  of  the  uterus  may  result  from  congeni- 
tal causes;  relaxation  of  the  intra-abdominal  uterine  supports; 
destruction  of  cervical,  vaginal,  and  perineal  uterine  supports  by 


396  SUPPLEMENTARY  CHAPTERS 

child-birth  lacerations;  or  the  sagging  backward  of  a  uterus  that 
is  for  any  reason  much  increased  in  size. 

Symptoms. — In  a  fairly  large  proportion  of  cases  of  retrover- 
sion  of  the  uterus,  it  is  highly  probable  that  no  symptoms  occur. 
Where  these  do  occur,  they  are  apt  to  be  somewhat  indefinite, 
suggesting  rather  than  positively  indicating  a  pelvic  disorder. 
The  usual  symptoms  would  be  dysmenorrhcea,  sacral  or  lumbo- 
sacral  backache,  mild  leucorrhcea,  and,  possibly,  constipation. 

Treatment. — The  treatment  of  retroversion  of  -the  uterus 
resulting  from  any  of  the  first  three  causes  mentioned  above 
would  be  an  operative  restoration  of  the  parts  to  normal.  Where 
the  condition  results  from  the  fourth  cause,  the  use  of  local  and 
general  medication,  accompanied  by  the  manual  restoration  of 
the  uterus  to  its  normal  position  and  its  retention  there  by  vaginal 
packing  or  pessary,  would  be  tried  before  operative  measures 
were  employed. 

4.  Retroflexion  of  the  Uterus.     Definition. — Retroflexion  of 
the  uterus  is  an  acute  bending  backward  of  the  uterine  body 
towards  the  pouch  of  Douglas,  the  vaginal  portion  of  the  cervix 
maintaining  its  normal  position  pointing  posteriorly. 

Causes. — Retroflexion  of  the  uterus  results  from  the  same 
causes  as  does  retroversion.  It  is  quite  probable,  however,  that 
a  more  relaxed  condition  of  the  uterine  musculature  is  necessary 
for  the  occurrence  of  the  former. 

Symptoms. — The  symptoms  of  retroflexion  of  the  uterus  are 
composed  of  a  complex  of  those  accompanying  retroversion  of  the 
uterus  and  anteflexion  of  the  cervix.  Unlike  retroversion,  symp- 
toms are  very  likely  to  occur.  These  would  be  dysmenorrhoea 
(usually  of  the  obstructive  type  that  accompanies  anteflexion), 
sacral  or  lumbosacral  backache,  leucorrhoea,  and  constipation, 
the  last  mentioned  being  of  more  frequent  occurrence  and  more 
obstinate  type  than  that  usually  encountered  in  retroversion. 

Treatment. — The  treatment  is  similar  to  that  for  retroversion. 

5.  Prolapse   of   the    Uterus.     Definition. — Prolapse   of    the 
uterus  is  a  descent  of  the  uterus  to  a  position  lower  than  the 
normal,    usually   carrying  with   it   the   immediately   adjoining 
structures.     It  may  be  divided,  according  to  the  extent  of  the 
process,  into  the  following  three  degrees:  (1)  descent  of  the  uterus, 
where  there  is  only  a  moderate  departure  from  the  normal  level; 
(2)  incomplete  prolapse,  where  the  departure  is  more  marked,  but 
the  uterus  does  not  protrude  from  the  vagina;  and  (3)  complete 


GYNAECOLOGICAL  CONDITIONS  397 

prolapse,  where  the  uterus  protrudes  from  the  vagina,  inverting 
and  carrying  with  it  the  vaginal  wall  and  forming  what  is  really 
a  hernia  of  the  pelvic  contents. 

Causes. — The  causes  may  be  congenital  or  acquired.  The 
most  serious  of  the  latter  is  destruction  of  the  pelvic  floor  by 
child-birth  lacerations.  Increased  size  of  the  uterus,  accompanied 
by  relaxed  ligaments  and  perineal  lacerations,  would  form  the 
usual  causal  elements. 

Symptoms. — The  symptom  that  most  usually  causes  the 
patient  to  seek  medical  advice  is  a  protrusion  of  the  cervix  from 
the  vulva.  Accompanying  or  preceding  this,  there  are  apt  to 
occur  leucorrhcea,  a  dragging  pain  throughout  the  pelvic  region, 
backache,  and,  possibly,  dysmenorrhcea. 

Treatment. — The  treatment  is  nearly  always  operative,  al- 
though in  the  milder  degrees  the  use  of  tampons  and  pessaries  may 
first  be  tried. 

II.  INJURIES 

1.  Laceration  of  the  Uterine  Cervix.   Definition. — Laceration 
of  the  cervix  is  a  tearing  of  the  uterine  cervix  by  the  application  of 
direct  violence.    The  tear  may  be  unilateral,  bilateral,  or  stellate, 
and  usually  follows  child-birth. 

Causes. — The  most  usual  cause  of  cervical  laceration  is  the 
passage  of  the  child  during  labor,  although  the  cervix  is  occasion- 
ally torn  during  the  process  of  instrumental  or  manual  dilatation. 

Symptoms. — In  the  majority  of  cases  there  are  probably  no 
symptoms  beyond  a  slight  leucorrhceal  discharge.  Where  the 
laceration  is  very  extensive,  it  may  be  contributive  to  a  displace- 
ment of  the  body  of  the  uterus,  and  will  then  be  accompanied  by 
the  usual  symptom  of  such  condition. 

Treatment. — The  treatment  consists  in  operative  repair.  This 
is  important,  even  where  no  severe  symptoms  occur,  as  unrepaired 
lacerations  are  the  usual  site  of  carcinoma  of  the  cervix. 

2.  Laceration  of  the  Perineum.   Definition. — The  term  "  lac- 
eration of  the  perineum"  is  used  to  include  any  break  of  the 
tissues  at  the  posterior  margin  of  the  vaginal  introitus  due  to 
violence.    These  lacerations  are  sometimes  classified  into  three 
degrees  for  the  sake  of  convenience,  the  first  degree  including  tears 
of  the  skin  and  subcutaneous  tissue  only,  and  not  really  extending 
into  the  true  perineum;  the  second  degree  including  more  severe 
tears  involving  the  levatores  ani  muscles,  but  not  the  sphincter  ani 


398  SUPPLEMENTARY  CHAPTERS 

or  rectum;  and  the  third  degree  including  the  most  severe  type, 
those  involving  the  sphincter  ani  muscle  and  even  the  rectal  wall. 

Causes. — The  vast  majority  of  perineal  lacerations  are  the 
result  of  child-birth,  either  following  over-distention  and  conse- 
quent rupture  by  the  passage  of  the  child  or  by  the  use  of  instru- 
ments by  the  accoucheur.  Perineal  laceration  occasionally 
follows  a  fall,  as  on  a  picket  fence. 

Symptoms. — In  the  first-degree  perineal  lacerations  symptoms 
are  usually  lacking.  In  the  milder  second-degree  lacerations  the 
same  is  frequently  true.  In  the  more  severe  second-degree 
lacerations  there  are  leucorrhcea,  constipation,  resulting  from 
the  pouching  forward  of  the  anterier  rectal  wall  to  produce  a 
rectocele,  and  quite  probably  accompanying  symptoms  of  pelvic 
congestion  due  to  a  more  or  less  marked  degree  of  uterine  descent, 
which  frequently  follows  this  destruction  of  the  pelvic  floor.  In 
third-degree  lacerations  the  symptoms  are  those  of  severe 
second-degree  tears,  combined  with  incontinence  of  faeces  result- 
ing from  the  torn  sphincter  ani  muscle  and  irregular  bleeding 
from  the  everted  rectal  mucosa. 

Treatment. — The  treatment  is  operative  and,  in  the  more 
severe  cases,  requires  a  higher  degree  of  operative  skill  than 
almost  any  other  form  of  gynecological  surgery. 

Genital  Fistulae.  Definition. — An  abnormal  opening  connect- 
ing the  genital  tract  (vagina,  uterus)  with  the  intestinal  tract 
(small  intestine,  rectum),  or  with  the  urinary  tract  (bladder, 
urethra,  ureter). 

Causes. — Injury  resulting  from  prolonged  or  difficult  labor, 
and  from  obstetric  or  gynaecological  operations.  Sloughing,  the 
result  of  local  inflammatory  or  malignant  disease,  may  be  a  cause. 

Symptoms. — The  escape  through  the  vagina  of  either  urine 
or  f«cal  matter  and  flatus,  with  the  distressing  local  irritation 
resulting. 

III.  INFLAMMATIONS 

In  the  vast  majority  of  cases,  gynaecological  inflammatory 
conditions  are  of  bacterial  origin,  and  consequently  the  inflam- 
mation is  the  evidence  of  an  infection.  Of  the  pathogenic  micro- 
organisms, those  most  frequently  found  in  gynaecological 
infections  are  the  gonococcus,  the  B.  coli  communis,  the  strepto- 
coccus,  the  staphylococcus,  and  the  B.  tuberculosis.  Of  these,  the 
gonococcus  is  much  the  most  frequent  cause  of  serious  trouble. 


GYNAECOLOGICAL  CONDITIONS  399 

The  streptococcus  and  staphylococcus  appear  to  be  normal 
inhabitants  of  the  vagina,  only  occasionally  causing  serious 
trouble,  and  the  colon  bacillus  is  a  near  neighbor,  being  a  normal 
inhabitant  of  the  large  intestine  and  occasionally  causing  trouble 
by  migrating  to  the  urinary  or  genital  tract. 

1.  Vulvitis.    Definition. — Vulvitis  is  an  inflammation  of  the 
vulva,  or  external  genital  organs. 

Cause. — The  usual  cause  of  vulvitis  is  infection  with  one  of  the 
pathogenic  microorganisms,  generally  the  gonococcus.  The  condi- 
tion may,  however,  result  from  irritating,  non-infectious  vaginal 
discharges;  from  urine  in  diabetic  and  some  other  conditions;  from 
thread-worms  coming  from  the  rectum ;  or  from  uncleanliness. 

Symptoms. — First  are  the  classical  local  symptoms  of  inflam- 
mation— heat,  pain,  redness,  and  swelling.  There  is  more  or  less 
mucopurulent  discharge.  There  may  be  constitutional  symp- 
toms, as  general  malaise,  moderate  fever,  and  headache. 

Treatment. — Where  the  condition  proves  infectious,  the 
treatment  is  local  and  general.  The  local  treatment  consists  in 
maintaining  cleanliness  by  frequent  irrigations  with  a  mild 
antiseptic  solution  and  in  the  direct  application  of  germicides, 
such  as  argyrol  or  silver  nitrate  in  solution,  or  one  or  more  medica- 
ments combined  in  powder  or  ointment  form.  The  general  treat- 
ment consists  of  rest  in  bed,  free  catharsis,  and  a  fairly  free  diet. 
Great  precautions  must  be  taken  to  prevent  further  conveyance 
of  the  infection.  The  materials  used  for  applications  should  be 
burnt.  No  one  else  should  use  the  patient's  towels  or  wash- 
cloths. 

All  dressings  and  napkins  should  be  thoroughly  soaked  in  an 
antiseptic  solution  before  washing. 

2.  Vaginitis.    Definition. — Vaginitis  is   an   inflammation   of 
the  vagina. 

Causes. — The  causes  of  vaginitis  are  identical  with  those  of 
vulvitis,  which  it  frequently  accompanies,  except  that  it  is  not 
likely  to  accompany  diabetes. 

Symptoms. — The  symptoms  are  the  same  as  those  for  vulvitis, 
except  for  the  greater  frequency  of  constitutional  symptoms  and 
the  presence  of  a  discharge  that  evidently  originates  from  above 
the  vulva. 

Treatment. — The  treatment  during  the  acute  stage  is  the  same 
as  for  vulvitis.  Absolute  rest  in  bed  is  possibly  of  more  vital 
importance,  as  danger  of  extension  to  the  uterus,  tubes,  and 


400  SUPPLEMENTARY  CHAPTERS 

pelvic  cavity  is  more  immediate.  After  the  acute  stage  has 
subsided,  various  local  applications  may  be  made  by  douche,  swab 
or  tampon. 

3.  Endometritis.     Definition. — Endometritis  is  an  inflamma- 
tion of  the  lining  of  the  uterus. 

Causes. — Endometritis  may  be  caused  by  the  introduction 
of  any  of  the  pathogenic  microorganisms  that  could  give  rise  to 
vaginitis  or  vulvitis,  and  is  frequently  the  result  of  an  upward 
extension  of  these  conditions. 

Symptoms. — During  the  acute  stages  the  symptoms  of 
endometritis  are  those  common  to  any  inflammation  of  the  upper 
genital  tract:  (1)  leucorrhceal  discharge,  generally  of  a  purulent 
or  mucopurulent  character  in  the  infectious  cases;  (2)  local  pain 
in  the  pelvic  region,  either  median  or  lateral;  (3)  menstrual 
irregularity,  occuring  as  metrorrhagia,  menorrhagia,  or  both ; 
and  (4)  constitutional  symptoms,  consisting  of  elevation  of 
temperature  and,  frequently,  loss  of  appetite.  During  the 
subacute  and  chronic  stages  the  constitutional  symptoms  are 
usually  lacking;  the  discharge  becomes  more  decidely  mucous  in 
character;  the  menstrual  disorders  diminish  or  disappear,  and  the 
pelvic  pain  becomes  less  intense  or  disappears. 

Treatment. — The  treatment  during  the  acute  stage  is  similar 
to  that  of  vaginitis.  If,  after  the  subsidence  of  the  acute  stage, 
marked  symptoms  persist,  the  treatment  is  usually  operative, 
although  local  applications  may  be  made  to  the  endometrium  in 
the  hope  of  achieving  a  cure  without  resorting  to  surgery. 

4.  Salpingitis.    Definition. — Salpingitis    is   an  inflammation 
of  the  Fallopian  tube.    It  may  be  unilateral  or  bilateral.    Accord- 
ing to  its  type  and  degree  of  progress,  Salpingitis  may  be  classified 
as  follows:     (1)  Salpingitis,  an  uncomplicated  inflammation  of 
the  Fallopian  tube;  (2)  pyosalpinx,  an  enlarged  and  inflamed 
Fallopian  tube  which  contains  free  pus;  (3)  salpingo-oophoritis, 
an  inflammation  of  both  Fallopian  tube  and  ovary;  (4)  tubo- 
ovarian  abscess,  an  inflammation  of  both  Fallopian  tube  and 
ovary  that  has  gone  on  to  abscess  formation;  and  (5)  pelvic 
abscess,  a  condition  in  which  one  or  more  of  the  preceding  con- 
ditions is  complicated  by  the  presence  of  walled-off  pus  in  the 
pelvic  cavity. 

Causes. — The  causes  of  these  different  varieties  of  salpingitis 
are  the  same  as  those  of  endometritis. 


GYNECOLOGICAL  CONDITIONS  401 

Symptoms. — The  symptoms  are,  in  varying  degree,  those 
already  enumerated  as  characteristic  of  pelvic  inflammatory 
process. 

Treatment. — The  treatment  of  these  conditions,  during  the 
acute  stage,  is  the  same  as  for  endometritis.  The  use  of  sup- 
portive and  anodyne  measures  is,  however,  usual — the  rectal 
administration  of  salt  solution;  the  employment  of  the  Fowler 
position;  the  use  of  a  suprapubic  ice-bag,  and  the  hypodermic 
administration  of  morphine  being  almost  routine.  The  operative 
removal  of  the  diseased  organ  or  the  evacuation  of  the  abscess 
cavity  by  the  vaginal  or  abdominal  route  nearly  always  follows 
the  subsidence  of  acute  symptoms,  and  may  be  required  earlier 
by  the  appearance  or  persistence  of  alarming  symptoms. 

IV.  NEW-GROWTHS 

In  the  present  discussion  of  the  gynaecological  neoplasms  no 
effort  will  be  made  towards  either  a  pathological  or  organic 
classification  or  description.  We  shall  consider  only  three  types 
of  tumors,  and  those  only  as  they  occur  in  two  organs:  cysts  of 
the  ovaries,  and  fibroid  tumors  and  cancers  of  the  uterus. 

1.  Ovarian  Cyst.  Definition. — An  ovarian  cyst  is  a  tumor 
whose  walls  consist  of  the  ovary  and  whose  contents  are  fluid. 

Cause. — The  cause  of  this,  as  indeed  of  other  forms  of  new- 
growths,  is  unknown. 

Symptoms. — The  earliest  symptom  of  an  ovarian  cyst  is  that 
of  almost  any  disorder  of  the  upper  genital  tract — irregularity  of 
menstruation,  either  menorrhagia  or  metrorrhagia.  There  may 
be  pain  in  the  region  of  the  affected  ovary,  extending  down  the 
thigh  on  the  same  side.  Subsequently  there  is  a  steadily  increas- 
ing enlargement  of  the  abdomen,  which  may  assume  enormous 
proportions  if  permitted  to  progress  uninterrupted. 

Treatment. — The  treatment  consists  in  the  operative  removal 
of  the  diseased  organ. 

2.  Fibroid  Tumor  of  the  Uterus  (Fibroma  Uteri).  Definition. — 
These  tumors,  as  the  name  will  indicate,  are  new-growths 
originating  in  the  connective-tissue  elements  of  the  uterus. 
When  occurring  within  the  walls  of  the  uterus,  they  are  called 
intramural;  when  just  beneath  the  peritoneal  covering,  sub- 
serous;  and  when  just  beneath  the  mucous  lining,  submucous. 

Cause. — The  cause  is  unknown. 

Symptoms. — The  first  symptom  is  usually  uterine  hemorrhage, 
26 


402  SUPPLEMENTARY  CHAPTERS 

occurring  with  or  between  the  menstrual  periods  and  ordinarily 
becoming  progressively  more  severe.  As  the  growth  progresses, 
abdominal  enlargement  occurs,  sometimes  as  a  single  mass  and 
sometimes  as  several  globular  masses.  There  may  be  pelvic 
pain;  symptoms  due  to  pressure  on  the  rectum  and  bladder; 
and,  frequently,  anaemia  due  to  excessive  loss  of  blood. 

Treatment. — The  usual  treatment  is  operative — either  the 
enucleation  of  the  growth  when  possible,  or  the- removal  of  the 
uterus  and  growth  together  when  necessary.  Recently,  treatment 
by  Rontgen  ray  and  by  radium  has  given  promise  of  encourag- 
ing results. 

3.  Cancer  of  the  Uterus  (Carcinoma  Uteri).  Definition  — 
Carcinoma  of  the  uterus  is  a  highly  malignant  new-growth  of  that 
organ,  arising  from  its  epithelial  elements  and  frequently  spread- 
ing to  other  parts  of  the  body  by  metastasis.  Its  most  frequent 
and  malignant  location  is  in  the  cervix,  usually  at  the  site  of  an 
old,  unrepaired  laceration. 

Cause. — The  cause  is  unknown. 

Symptoms. — The  more  positive  and  definite  symptoms  of 
carcinoma  of  the  uterus  are  usually  of  such  late  occurrence  that 
their  arrival  should  not  be  awaited  before  attempting  a  diagnosis. 
Any  unusual  bleeding  from  the  uterus  or  leucorrhoeal  discharge 
after  thirty-five  years  of  age  should  lead  to  a  careful  examination 
by  a  competent  physician  and,  in  case  of  further  doubt,  the 
microscopical  examination  of  exsected  tissue.  The  later  symp- 
toms are  hemorrhage;  offensive,  irritating  leucorrhoea;  pelvic 
pain,  and,  possibly,  bladder  or  rectal  symptoms  from  the  exten- 
sion of  the  growth. 

Treatment. — The  curative  treatment  consists  in  early  diag- 
nosis and  radical  operative  removal  of  the  diseased  area  and  such 
immediately  adjoining  healthy  tissues  as  may  be  safely  taken. 
This  would  include  uterus,  Fallopian  tubes,  ovaries,  and  part  of 
the  parametrium  and  vagina.  In  late  cases  the  palliative  treat- 
ment consists  in  the  control  of  symptoms  and  the  delay  of  the 
disease's  progress  by  use  of  the  knife,  cautery,  chemicals,  opiates, 
and,  possibly,  the  Rontgen  ray  or  radium. 


INDEX 


Abbreviations,  86 
Abdomen,  bandages  of,  125 
distention  of,  with  gas,  206 
surgical  diseases  of,  390 
Abdominal  binder,  274 
pads,  rack  for,  255 
supports,  postoperative,  221 
Abscess,  42,  44,  91,  382,  386 
pelvic,  400 
tubo-ovarian,  400 
Absorbable  sutures,  264 
Absorption  by  cells,  10 
Accident  cases,  hemorrhage  in,  364 

transportation  of,  363 
Accidental  injuries,  diagnosis  of,  363 

wounds,  first  aid  in,  357 
Accuracy  in  observation,  190 
Acquired  defects  and  deformities,  379 
Active  and  passive  congestion,  149 

treatment,  59 
Acute  disease,  56 
Adaptation,  16,  29,  65,  69 
in  cells,  12 

of  parasite  to  host,  29 
Adaptive  changes,  65,  67,  69 
Adhesive  plaster,  137,  260,  275 
double-faced  (Janus),  260 
for  Buck's  extension,  138 
for  fractured  ribs,  141,  336 
in  operating-room  supplies,  260 
to  apply  without  kinking,  138 
to  fix  padding  on  splints,  136 
to   secure    fracture   dressings, 

137 
to  secure  wound  dressings,  37, 

115,  116,  125,  157,  159 
with  tapes,  116,  157 
straps  with  tapes,  157 
Aerobic  bacteria,  49 
Affection,  55,  89 


Air,  infection  through,  5,  33 

Allis's  blunt  dissector,  292 

Amputating  knives  (see  Cutting  in- 
struments) 

Amputation  set,  instruments  for,  331, 
332,  333 

Amputations,  steps  in,  342 

Amyloid  degeneration,  81 

Anaemia,  57 

Anaesthesia,  57 

combined  local  and  general,  233 

discovery  of,  4 

effect  of  discovery,  4 

emergencies  in,  317 

in  exophthalmic  goitre,  234 

local,  formula)  for,  175 

local,  with  novocaine,  233 

with  quinine  and  urea  hydro- 
chloride,  233 
twofold  benefits  of,  4 
verbal  suggestion  in,  239,  240 
with  nitrous  oxide  and  oxygen, 
231,  233,  238 

Anaesthetic,  31 

dangers  from,  317,  347 
in  private  house,  347 

Anaesthetist,  233,  243,  311,  314,  317 
duties  of,  in  assisting,  317 
equipment  for,  311,  312 
nurse  as,  233,  244,  315 
responsibility  of,  243,  314 

Anaesthetized  patient,  care  of,  317, 
319 

Anesthetizing  room,  246 

Anaerobic  bacteria,  49 

Anastomosis,  94 

Anatomical  defects,  89,  377 

Aneurism,  390 
needle,  291 

Ankle,  fractures  of,  first  aid  in,  361, 
363 

403 


404 


INDEX 


Anoci-asso elation,  229  et  seq. 

nurse's  part  in,  234 
Anteflexion  of  the  uterine  cervix,  395 
Anterior  poliomyelitis,  379 
Antisepsis,  introduction  of,  6,  95 
Antiseptic,  definition  of,  298;  era,  7 

solutions,  formulae  for,  175 
Antitetanic  serum,  359 
Antitoxins,  76 
Appendectomy,  338 
Appendicitis,  91,  391 
Appendix  set,  instruments  for,  325 
Apron,  rubber,  256 
Arm,  fractures  of,  first  aid  in,  361 
Arterial  hemorrhage,  381 
Articulations  (see  Joints) 
Artificial  respiration,  317,  369 
Aseptic  era,  7 

surgical  technic,  8,  296  el  seq. 
wound,  34 

Ashby's  vaginal  speculum,  238 
Aspirating  needles,  294 

care  of,  295 
Assembling  and  handling  sterilized 

outfit,  302 

Astringent  drugs  in  hemorrhage,  367 
Atresia  of  the  vagina,  395 
Atrophy,  56,  80 
Attention  to  bandages  and  dressings, 

210 

in  observation,  190 
Attitude,  mental,  in  meeting  emer- 
gencies, 356 
mental,  of  hospital  team,  235 

toward  pain,  207 
personal,  of  nurse,  372 
Auscultation,  58 
Autoclave,  248 

Auvard's  vaginal  speculum,  288 
Auxiliary  instruments,  290  to  295 
dilators,  292  to  294 

Kelly's  urethral  dilator,  294 
Palmer's  cervical  dilator,  292 
Pratt-Hank's  uterine   dilator, 
292 


Auxiliary  instruments,  Pratt's  rectal 
dilator,  294 

urethral  sound,  294 

Wale's  rectal  bougie,  294 

Wathen's  cervical  dilator,  292 

Weiss's  urethral  sound,  294 
directors,  292,  293 

plain  grooved  director,  292 

probe-pointed   grooved   direc- 
tor, 292 
dissectors,  292,  293 

Allis's  blunt  dissector,  292 

Massachusetts    Gener'al    Hos- 
pital blunt  dissectors,  292 

periosteal  elevators,  292 
evacuators,  293,  294,  295 

aspirating  needles  (exploring), 
294 

Birch's  trocar  and  cannula,  294 

catheters,  294 

male  catheter,  294 

Emmet's  ovarian  trocar  and 
cannula,  294 

female  catheter,  294 

Hagner's  double-current  cathe- 
ter, 294 

Nott's    double-current    cathe- 
ter, 294 

Ochsner's  gall-bladder  trocar 
and  cannula,  294 

Skene's  self -retaining  catheter, 
294 

Tait's  ovarian  trocar,  294 
searching  instruments,  293,  294, 
295. 

silver  probe,  292 

Thompson's    stone    searcher, 
292 

Sims's  uterine  sound,  292 
Axillary  splint,  135 


B 

Bacillus,  18,  26 

aerogenes  capsulatus 
50,  359 


,   48, 


INDEX 


405 


Bacillus  coli  communis,  48,  398 

diphtheria?,  20,  31 

pyocyaneus,  48 

tetani,  49,  359 

tuberculosis,  50,  91,  398 
Bacteria,  6,  18,  22,  25,  26,  27 

aerobic,  22 

anaerobic,  22 

colonies  of,  22 

color  in  colonies,  22 

concerned  in  wound  infection,  46 

description  of,  18 

distribution  of,  26 
.  facultative,  22 

in  air,  5,  26,  29 

in  food,  27 

in  human  body,  27,  45 

in  soil,  27,  359 

in  water,  26 

in  wound  infection,  46 

inhibition  of  growth  of,  298 

motility  of,  22 

multiplication  of,   19 

number  of  pathogenic;  species,  25 

pathogenic,  20 

saphrophytic,  20 

septic  carriers  of,  31,  45,  299 

size  of,  19 

spore-bearing,  22 

thermal  death  point  of,  298 
Bacteriology,  beginning  of,  6 
Balance  in  cell  activities,  17,  60 
Baldy- Webster    operation,    steps    in, 

340 

Balkan  Frame,  138 
Bandage,  Esmarch,  258 

roller,  273 
Bandages,  application  of,  114 

attention  to,  210 

constriction  from  tight,  211 

forms  and  uses  of,  111 

materials  and  preparation  of,  1 12 

method  of  rolling,  114 

of    chest,    method    of    relieving 
when  too  tight,  210 


Bandages,  pressure  from,  117,  210 

swelling  of  limb  below,  117 
Bandaging,  for  fixation,  116,  139,  140 

for  pressure,  118 

for  retention  of    dressings,   114 

principles  of,  109,  110 

regional,  122 

turns  used  in,  118 

Bartlett's  method  of  sterilizing  cat- 
gut, 269 

Basins  for  solutions,  254 
Bastianelli's     skin     disinfection     by 

iodine,  305 
Bath,  continuous,  in  local  infections, 

149,  386 
Batiste,  273 
Bed,  position  in,  202 

fracture,  138 

sores,  385 

Belts,  postoperative,  221 
Benign  tumors,  79,  388,  401 
"Berlin"  rinsing  curette,  280 
Bichloride  of  mercury,  22 

formula  for  solutions  of,  175 
Bier's  hypersRmia,  149 
Binders,  postoperative,  221 
Birch's  trocar  and  cannula,  294 
Bismuth  paste,  150 
Bistouries,  279 
Bladder,  exstrophy  of,  378 

irrigation  of,  154 

rupture  of,  383 
Blake's  curette,  280 
Blanket  splint,  361 
Blebs,  382 
Blisters,  382 

Bleeding  (see  Hemorrhage) 
Blood,  cells  of,  75 

clotting  of,  67 

collateral  circulation  of,  67 
Bodenhamer's  rectal  speculum,  288 
Boiling  water,  articles  to  be  steril- 
ized by,  301 
Boils,  91 
Bone-cutting  forceps,  281,  283 


406 


INDEX 


Bone  wax,  Horseley's,  271 

Bow  legs,  379 

Bradford's  frame,  138 

Brim's  gouge,  281 

Buck's  currette,  280 
extension,  138 

Burns,  63,  380,  384 
first  aid  in,  359 
open  treatment  of,  151 
paraffin  wax  for,  177 
occlusion  treatment,  150 

Burrs,  279,  330 


Cabot's  splint  for  leg,  135 

Calcareous  degenerations,  81 

Calculi,  92 

Cancer  of  uterus,  402 

Cannulae  and  trocars,  care  of,  295 

Cap,  operating-room,  256 

Capillary  hemorrhage,  381 

Capital  operation,  94 

Carbohydrates,  81 

Carbolic  acid,  5,  22 

spray  as  used  by  Lister,  5 
Carbuncles,  91 
Carcinoma,  80,  388,  391,  402 

of  breast,  375 

of  intestine,  391 

of  stomach,  391 

of  uterus,  402 

Cardinal  signs  of  inflammation,   42 
Care   of  anaesthetized  patient,   317, 
319 

rubber  articles,  258 
Caro's  urethral  speculum,  288 
Carrel-Dakin  technic,  160 

tubes,  163 

Carriers    of    disease    organisms,    31, 
32,  46 

of  septic  bacteria,  men  and  ani- 
mals as,  31,  45,  299 
Carston's  ligature  carrier,  291 
Caseous  degeneration,  81 
Catarrhal  appendicitis,  391 


Catgut,  264 

method  of  preparing,  267 
methods  of  sterilizing,  267 
plain  and  chromicized,  268 
sutures,  objections  to  use  of,  267 
and   ligatures,   absorption  of, 

268 

indications  for,  287 
Catheterization    in    female,    tecl  nic 

of,  143 
Catheters,    258,    294    (see    Auxiliary 

instruments) 
Catling  knife,  279 

Causes  of  disease,  54,  56,  62,  63,  64 
Cell,  activities  of,  10 

as  unit  of  living  matter,  8 

form  and  structure,  9 

of  human  tissues,  thermal  death 

point  of,  64 
qualities  of,  11 
vital  requirements  of,  10 
Cell  activities,  changes  in,  65 

perverted,  78 
Cellular  pathology,  60 
Cellulitis,  385 
Centimetre,  English   equivalent   of, 

170 

Charts,  cover  sheet,  180 
description  of,  180 
medicine  and  treatment  sheet, 

184 

record  sheet,  180 
temperature  sheet,  180 
Chemical  causes  of  disease,  6 
cell  activities,  12 
solutions,  articles  to  be  steril- 
ized by,  302 
supplies,  259 
Chest,  bandages  of,  125 

tight  bandages  of,  210 
Chisel  and  osteotome,  difference  be- 
tween, 281 

Chisels  (see  Cutting  instruments) 
Chloramine-T.,  168 
Chloramine-T.  Paste,  168,  177 


INDEX 


407 


Cholecystectomy,  338 
Cholecystotomy,  338 
Choledochotomy,  338 
Cholelithiasis,  394 
•  Chromatin,  9 
Chromoplasm,  9 
Chronic  disease,  56 
Cicatrization,  56 
Cigarette  drains,  271 
Circulation,  collateral,  67 
Clamping  instrument,  283,  284 
haemostatic  clamps,  284 
Halsted's  clamp,  284 
Halsted's  mosquito  clamp,  284 
Kelly's  clamp,  284 
Kocher's  clamp,  294 
Ochsner's  clamp,  284 
Pean's  clamp,  284 
Tait's  clamp,  284 
von  Blunk's  clamp,  284 
hemorrhoidal   clamp    (Kelsey's), 

283 

intestinal  clamps,  384 
Kocher's,  284 
Wright's,  284 
Pean's  pedicle  clamp,  284 
stomach    clamp       (Mayo-Rob- 
son's),  284 

Classification  of  symptoms,  57 
Claudius  method  of  sterilizing  cat- 
gut, 270 
Clavicle,   fractures  of,   first  aid  in, 

361 

Clean  wound,  34 
Cleft  palate,  89,  377 
Cleveland  ligature  carrier,  291 
Clinical  diagnosis,  59 

surgery,  82 
Clotting  of  blood,  67 
Club  foot,  379 
Coaptation  splints,  135 
Cold  to  control  hemorrhage,  367 

uses  of,  203 

Collar  bone,  fractures  of,  first  aid  in, 
^361 


Collateral  circulation,  67,  382 

CoHin's  uterine-holding  forceps,  285 

Colloid  degenerations,  81 

Colon  bacillus,  48,  398 

Color  in  colonies  of  bacteria,  20 

Comfort  of  patient,  measures  for,  201 

Comminuted  fractures,  382 

Compensatory  changes,  66 

Complication,  56 

Compound  fractures,  360,  382 

Compresses,  272 

Concealed  hemorrhage,  382 

Congenital  defects,  378 

deformities,  377 
Congestion,  active  and  passive,  148 
Connective-tissue  cells,  15,  70,  71 
Constitutional  symptoms,  57 
Constructive  tissue  changes,  79 
Contact  infection,  262 
Continuity  of  cell  life,  13 
Continuous  bath,  386 

irrigation  in  infected  wounds,  149 

proctoclysis,  146 
Contused  wound,  34 
Costume,  operating-room,  256 
Cotton,  260 

absorbent,  260 
Cranial    set,    instruments    for,    330, 

331,  332 

Craniotomy,  steps  in,  337 
Crepe  lisse,  273 
Crepitus,  383 
Crinoline  bandage,  112 
Cubic  centimetre,  26 

English  equivalent  of,  171 
Curettage  set,   uterine,   instruments 

for,  329,  330 
Curettes  (see  Cutting  instruments), 

280,  283 
Cutting  instruments,  278  to  283 

bone-cutting  forceps,  281  to  283 
Darby's  rongeur  forceps,  281 
Gluck's  rib  shears,  281 
Liston's  bone-cutting  forceps, 
281 


408 


INDEX 


Cutting  instruments 
bone  cutting: 

Luer's    rongeur    forceps,    281 

Velpeau's  bone  cutters,  281 
bone  drills,  279,  280,  330,  332 

burrs,  279,  330 

Hamilton's  bone  drill,  280 

Hudson's  cranial  set,  330 
chisels  and  gouges,  281 

Brun's  gouge,  281 

McEwen's  chisel,  281 

McEwen's  gouge,  281 

McEwen's  osteotome,  281 

Schwartze's  chisel  and  gouge, 

281 
curettes,  280,  283 

Blake's  curette,  280 

Buck's  curette,  280 

Luer's  curette,  280 

Martin's  curette,  280 

placenta  curette,  280 

rinsing  ("Berlin")  curette,  280 

Sims's  curette,  280 

spoon  curette,  280 

Thomas's  curette,  280 

Volkmann's  curette,  280 
knives,  278,  279 

amputating  knives,  279 

bistouries,  278,  279 

Catling     amputating     knife, 
279 

Liston's     amputating    knife, 
279 

scalpels,  278,  279 

tenotomy  knife,  279 
saws    and    trephines,    279,    280, 
282,  283,  332 

DeVilbiss's    conical    trephine, 
280 

Gait's  conical  trephine,  280 

Gigli's  wire  saw,  282 

Hey's  skull  saw,  282 

metacarpal  saws,  282 

Satterlee's  saw,  282 

Windler's  saw,  332 


Cutting  instruments 
scissors,  278,  279 

Emmet's  uterine  scissors,  279 
Lister's  bandage  scissors,  279 
Littauer's  suture  scissors,  279 
Mayo's  dissecting  scissors,  279 
sharp  and  dull  point  scissors, 

279 
umbilical  scissors,  279 

Cyanosis,  194 

Cyst  of  ovary,  401 

Cysticotomy,  338 

Cystoma,  388 

Cysts,  resting  stage  in  protozoa,  22 

Cytoplasm,  9 


Dakin's  solution,  161 

Darby's  rongeur  forceps,  281 

Defects,  acquired,  379 
anatomical,  89,  377 
congenital,  378 

Defences  against  infection,  72 

Deformities,  acquired,  379 
congenital,  377 

Degeneration,  56,  61,  81 

Depilatory     powder,     formula     for, 
178 

Desault  bandage,  128 

Destructive  tissue  changes,  79 

DeVilbiss's  trephine,  280 

Diagnosis,  58 

of  accidental  injuries,  363 

Diarrhrcal  diseases,  28 

Dichloramine-T.,  198 

Diet  in  surgical  cases,  209,  213,  216 

Differential  diagnosis,  59 

Dilatation  and  curettage  of  uterus, 
steps  in,  341 

Dilators,  292,  293,  294   (see  Auxil- 
iary instruments) 

Diphtheria  bacilli,  20,  31 

Diplococci,  18 

Directors,    292,    293    (see    Auxiliary 
instruments) 


INDEX 


409 


Disarticulation,  steps  in,  343 
Disease,  16,  55,  60 

acute,  56 

and  health,  16 

causes  of,  56,  62 

chronic,  56 

functional,  5fc,  57,  82 

gall-stone,  394 

organic,  56 

septic,  385 

specific,  56 
Disinfection,  definition  of,  298 

of  skin,  305 
Dislocations,  382,  383 
Dispensary,   gynaecological,   arrange- 
ment of,  351 

draping    of    patient    for    exam- 
ination in,  355 

drugs,  solutions,  etc.,  in,  355 

examining  and  treatment  room, 
352 

instruments  in,  355 

preparation  for  examination  in, 
354 

records  in,  351 
Dissecting  set,  instruments  for,  323 

324,  327 
Dissectors,    292    293    (see    Auxiliary 

instruments) 
Dorsal  position,  103 

splint  of  the  arm,  135 
Dorsosacral  position,  103,  107 
Double-current  catheter,  294 
Douche,  vaginal,  technic  of,  155 
Doyen's  retractor,  287 

tissue-holding  forceps,  285 
Drainage,  36,  44 

of  abscesses,  386 

of    bile,    observation    of,    after 
gall-stone  operations,  195,  394 
Drains,  270 
Draping  of  patient  for  examination, 

355 

Dress,  operating-room,  256 
Dressed  tube  drains,  270 


Dressing,  application  of  first,  321 

cart  or  carriage,  156 

forceps,  285 

of  burns,  150,  384 

room  (surgeon's),  246 

room  (ward),  157 

sterilizer,  248 
Dressings,  attention  to,  210 

care  of  perineal,  156 

drums  for  sterile,  254 

for  wounds,  271 

for  wounds,  material  for,  262 

observation  of,  141,  191,  210 
Dressings,  supplies,  159 

wet,  150,  204,  386 
Drills    (see   Bone   drills),    279,   280, 

330,  332 

Drugs  in   gynaecological  dispensary, 
355 

in  operating  room,  259 

pure,  solutions  from,  178 

styptic  and  astringent,  in  hem- 
orrhage, 367 

Drums  for  sterile  dressings,  254 
Dry  gangrene,  389 

treatment  of  burns,  151 
Duodenum,  ulcer  of,  390 
Dysentery,  28 

E 

Ear,  bleeding  from,  383 

Ecchymosis,  381 

Edebohl's  vaginal  speculum,  288 

Efficiency,  235,  236,  243,  244 

Ehrlich's  side-chain  theory,  76 

Elbow-joint,  fractures  near,  first  aid 
in,  361 

Elevated  dorsosacral  position,  104 

Emergencies,  356  et  seq. 

Emmet's  ligature  carrier,  291 

ovarian  trocar  and  cannula,  294 
scissors,  uterine,  279 
uterine  dressing  forceps,  285 

Empirical  treatment,  59 

Emphysema,  50,  194,  381 


410 


INDEX 


Endometritis,  400 
Endothelioma,  388 
Enema,  method  of  administration  of, 

143 

formulae  for,  176 
varieties  of,  145,  146 
Enteroptosis,  89 
Enuresis,  228 
Environment,  12 
Enzymes,  73 

Epithelial  cells,  15,  44,  71 
Epithelioma,  388 
Epitome  of  surgical  conditions,  377 

et  seq. 
Epitome  of  gynaecological  conditions, 

394  et  seq. 
Erect  position,  106 
Erysipelas,  47,  385 
Esmarch  bandage,  258 
Etherizing  room,  246 
Etiology,  56 
Evacuators,     293,     294,     295     (see 

Auxiliary  instruments) 
Excision,  94 

Exciting  causes  of  disease,  56 
Excretion  by  cells,  10 
Exophthalmic  goitre,  78,  389 
Exploratory  operation,  94 
Exploring  needles,  294 
Exposing  instruments,  284  to  289 
retractors,  284,  287,  289 

Doyen's  abdominal  retractor, 

287 

Freer 's  nasal  retractor,  286 
Halsted's  retractors,  286 
Jackson's     hysterectomy     re- 
tractor,  287 
Kelly's    abdominal    retractor, 

286,  287 
Langenbeck's    retractor,    286, 

287 

Richardson's  retractor,  286 
sharp  hook  retractors,  286 
Simon's  sharp  hook  retractor, 
286 


Exposing  instruments 
retractors : 
Simpson-Mayo     self-retaining 

retractor,  287 

Volkmann's    sharp    hook    re- 
tractor, 286 
Young's    prostatic    retractor, 

287 

Young's  vesical  retractor,  287 
specula,  288,  289 

Ashby's  vaginal  speculum,  288 
Auvard's  vaginal  speculum, 

288 

Bodenhamer's     rectal     specu- 
lum, 288 

Caro's  urethral  speculum,  288 
Edebohl's  vaginal  speculum, 

288 
Ferguson's  vaginal  speculum, 

288 

Grave's  vaginal  speculum,  288 
Halsted's  rectal  speculum,  288 
Kelly's  rectal  speculum,  288 

urethral  speculum,  288 
Matheiu's     rectal     speculum, 

288 
Nelson's     vaginal     speculum, 

288 
Pratt 's  sigmoid  speculum,  288 

urethral  speculum,  288 
Sims's  vaginal  speculum,  288 
Exstrophy  of  bladder,  378 
Extension    (Buck's),    apparatus   for, 

138 

Extensive    dissecting    set,       instru- 
ments for,  327 

Extremities,  bandages  of,  125 
Exudate,  inflammatory,  42 


Faces,  bacteria  in,  28 

Falling  of  the  womb  (see  Prolapse  of 

uterus) 
Fats,  81 
Fatty  degenerations,  81 


INDEX 


411 


Feeding  in  hare-lip  and  cleft-palate 
cases,  378 

of  surgical  patients,  209 
Feelings,  as  symptoms,  197 
Felt  splints,  135 
Female  catheter,  294 
Ferguson's    lion- jawed    forceps,    285 
Fermentation,  5 
Ferments,  73 
Fever,  57,  61,  64 

septic,  41 

traumatic,  38 
Fibrinous  exudate,  42 
Fibroid  tumor  of  uterus,  401 
Fibroma,  388 

uteri,  401 

Filterable  viruses,  23 
First  aid  by  nurse  in  accidents,  356 
et  seq. 

intention,  healing  by,  7,  71 
Fissure  in  ano,  instruments  for,  329 
Fistula,  intestinal,  206 
Fixation,  110, 139, 140 
Flannel  bandage,  113 
Flaps  in  operative  incision,  35 

osteoplastic,  36 
Fluffs,  271 
Focal  symptoms,  57 
Foerster's  forceps,  284 

sponge  or  dressing  forceps,  285 
Food,  bacteria  in,  27 

in  surgical  cases,  207 
Foot-drop,  avoidance  of,  203 
Forceps,  284,  285   (see  Holding  in- 
struments) 

bone-cutting,  281,  283  (see  Cut- 
ting instruments) 

Forearm,  fractures  of,  first  aid  in,  360 
Foreign  bodies,  89,  380 

left  in  abdominal  cavity,  380 
Formalin  vapor,  articles  to  be  ster- 
ilized by,  302 
Formula),  174-176 

for  antiseptic  solutions,  175 

for  depilatory  powder,  178 


Formulae,  for  cnemata,  176 
for  local  anaesthesia,  175 
for  ointments,  177 
for  pastes,  177 
for  saline  solutions,  176 
for     ap,  177 
for  vaginal  douches,  177 
for  Chloramine-T.  cream,  177 
for  Par  ffin  wax    or  burns  ,177 
for  Sinclair's  glue,  178 

Four-tailed  bandage,  111 

Fowler's  position,  151 

Fracture  bed,  138 
tables,  138 

Fractures,  382 

apparatus  for,  136-141 

at  base  of  skull,  383 

at  elbow-joint,  first  aid,  351 

compound,  360 

fixed  extension   and  tractor  in 

treatment  of,  135 

infection  in  compound,  5 

observation   after  dressing,   141 

of  ankle,  first  aid  in,  361,  363 

of  arm,  first  aid  in,  361 

of  clavicle,  first  aid  in,  361 

of  forearm,  first  aid  in,  360 

of  jaw,  first  aid  in,  362 

of  knee,  first  aid  in,  363 

of  leg,  first  aid  in,  361 

of  ribs,  first  aid  in,  363 

of  shoulder,  first  aid  in,  361 

of  thigh,  first  aid  in,  362 

of  wrist,  first  aid  in,  360 

simple,  360 

treatment  of,  134 

Freer's  retractor,  287 

Frost  gangrene,  64 

Functional  disease,   55,   56,  57,  72, 
82,  92 

G 

Gall-bladder    set,    instruments    for, 

325,  326 

Gall-stone  disease,  394 
Gall-stones,  92 


412 


INDEX 


Gait's  trephine,  280 
Gangrene,  7,  62,  64,  389 
frost,  64 
hospital,  7 

Gangrenous  appendicitis,  391 
Gas  bacillus,  50,  359 
Gauze,  absorbent,  259 
bandage,  112 
for  drains,  270 
medicated,  271 
rolls,  272 
General  abdominal  set,  instruments 

for,  323,  324 
symptoms,  57 
Genital  Fistulse,  398 
Genito-Urinary  surgery,  93 
Genu-pectoral  position,  105,  108 
Gigli's  saw,  282 
Glover's  needle,  289 
Gloves,    rubber,    257    (see    Rubber 

gloves) 

Gluck's  rib  shears,  281 
Glycogen,  81 
Goitre,  389 

exophthalmic,  78,  389 
Gonococcus,  52,  91,  398 
Gouges    (see    Cutting    instruments) 
Gowns,  operating,  257 
Grace's  sign,  58 

Gramme,  English  equivalent  of,  171 
Granulation,  healing  by,  72 
Graves's  disease,  78 

vaginal  speculum,  288 
Green  pus,  bacillus  of,  48 
Grooved  director,  292 
Gross  pathology,  CO 
Gutta-percha  tissue,  260,  273 
Gynaecological  examination,  draping 

patient  for,  355 
Gyna3cology,  93 


Habitual  host,  31 
Ha3mostatic  clamps,  284  (see  Clamp- 
ing instruments) 


Hagedorn  needle,  289 

needle  holder,  291 
Hagner's     double-current     catheter, 

294 

Halsted,  Dr.  W.  S.,  first  use  of  rub- 
ber gloves,  7 
-Hagedorn  needle,  289 
Halsted's  clamp,  284 

mosquito  clamp,  284 
mouse-toothed  forceps,  285 
rectal  speculum,  288 
retractor,  286 
Ham  splint,  135 
Hamilton's  bone  drill,  280 
Handkerchief's,  gauze,  for  dressings, 

271 

Hare-lip,  89,  377 
Hazards,    operative,    95,    97,    229, 

237 
Head,  bandages  of,  122 

operations,  step  in,  337 
Healing,  69 

by  first  intention,  7,  7] 
by  granulation,  72 
normal,  7,  16,  37,  69 
process,  16,  69 
Health  and  disease,  16 
Heat,  to  control  hemorrhage,  367 

sterilization  by,  300 
Hegar's  needle  holder,  291 
Haematoma,  381 
Hemorrhage,  arrest  of,  36 

control  in  accident  cases,  364 
from  ear  in  fractures  at  base  of 

skull,  383 
from    large    vessels,    immediate 

control  of,  368 
from  varicose  veins,  367 
heat  and  cold  in,  367 
postoperative,  222 
varieties  of,  381 
Hemorrhoid    set,     instruments    for, 

327,  328 

Hepaticotomy,  338 
Heredity,  effect  on  parasitism,  30 


INDEX 


413 


Hernia,  393 

operation    for    radical    cure    of, 

steps  in,  340 
set,  instruments  for,  327 
Herniotomy,  340 
Key's  saw,  282 
Hip-joint,    injuries    of,    first   aid  in, 

363 

Holden's   bone-holding  forceps,   285 
Holding  instruments,  286  to  289 
forceps,  284,  285 

Collins 's    uterus-holding    for- 
ceps, 285 

Doyen's     tissue-holding     for- 
ceps, 285 

dressing  forceps,  285 
Emmet's  uterine  dressing  for- 
ceps, 285 
Ferguson's  lion-jawed  forceps, 

285 
Foerster's  sponge  or  dressing 

forceps,  285 
Foerster's  straight  and  curved 

holding  forceps,  284 
Halsted's  mouse-toothed  for- 
ceps, 285 
Holden's  bone-holding  forceps, 

285 

Houze's    tongue-holding    for- 
ceps, 285 

Kelly-Murphy  forceps,  284 
Pean's  T-forceps,  284 
Richter's    volsellum    forceps, 

185 

Skene's  volsellum  forceps,  285 
straight  sponge  stick,  284 
Van  Buren's  sequestrum  for- 
ceps, 285 
tenaculum,  285 

Hollow  instruments,  care  of,  295 
Holmes,  Dr.  Oliver  Wendell,  4 
Homceothermism,  203 
Hook  retractors,  sharp,  286 
Horizontal  recumbent  position,   101 
Horsehair  for  sutures,  266 


Horseley's  bone  wax,  271 
Hospital,  attitude  of  nurse  towards, 
374 

gangrene,  7 

wadding,  260 
Host,  habitual,  30 

and  parasite,  25,  28,  29,  31 

relation  of  parasite  to,  28 
Hot-air  sterilizer,  247 
Hot  fomentations,  386 

pack,  150 

Hot-water  bottles,  proper  tempera- 
ture of,  64,  203 
Houze's     tongue  holding     forceps, 

285 
Hudson's  cranial  set,  330 

trephine,  330 

Human  body,  bacteria  in,  28 
Hunter,  John,  3 
Hyaline  degeneration,  81 
Hyperamia,  57 
Hyperacsthesia,  57 
Hyperplasia,  78 
Hypertrophy,  56,  66,  79 
Hypodermic  injection,  technicof,  151, 
152 

needles,  care  of,  295 
Hypodermoclysis,  208 

supplies  for,  159 
Hyposecretion,  78 
Hysterectomy,  steps  in,  341 


Ileus,  393 

Implantation  infection,  262 
Incised  wound,  34 
Incision,  35,  94 
Incontinence  of  urine,  227 
Infantile  paralysis,  379 
Infected  cases,  precautions  in,  211 
wounds,  3,  34,  41 

in  War,  160 
Infection,  17,  90 

by  air,  5,  26,  29,  33 

by  carriers,  31 


414 


INDEX 


Infection,  by  mouth  spray,  33 
carriers  of  septic,  31,  45,  299 
contact,  262 
defences  against,  72 
implantation,  262 
in  compound  fractures,  5 
In   wounds,   bacteria   concerned 

in,  46 

fever  in,  41 
modes  of,  45 
modes  of,  32 

of  wounds,  postoperative,  224 
septic,  91 
surgical,  385 

Inhibition  of  bacterial  growth,  298 
Injuries,  diagnosis  of  accidental,  363 

of  hip-joint,  first  aid  in,  363 
Injuries  of  knee,  first  aid  in,  363 
Inflammation,  67 

cardinal  signs  of,  42 
exudate  in,  42 
Insomnia,  57 
Inspection,  58 
Instrument  room,  246 
sterilizer,  251 
table,  254 
Instruments,  care  of,  295 

in  gynaecological  dispensary,  352 
selection  of,  323  et  seq. 
surgical,  278 

auxiliary,   290    (see   Auxiliary 

instruments) 
clamping,  284  (see  Clamping 

instrument) 

cutting,  278  (see  Cutting  in- 
struments) 
exposing,    289    (see   Exposing 

instruments) 

general   classification   of,    278 
holding,  283  (see  Holding  in- 
struments) 

sewing,    289    (see   Sewing   in- 
struments) 

Intercellular  substances,  10,  15 
Interest  in  observation,  190 


Internal  angular  splint,  135 
Intestinal  clamps,  284 

fistula?,     irritating        discharges 
from,  206 

needles,  289 

obstruction,  393 
postoperative,  223 

perforation,  391 
Intestine,  carcinoma  of,  391 
Intestines,  bacteria  in,  28 
Intravenous  infusion,  supplies  for,  159 
Intussusception,  89 
Iodine,  22 

in  skin  disinfection,  215,  305 

sterilization  of  catgut,  270 
Irrigating  stand,  255 
Irrigation,  rectal,  145 

bladder,  154 
Irritability  of  cells,  11 


Jackson's  retractor,  287 
Jaundice,  194 

Jaw,  fractures  of,  first  aid  in,  362 
Johns  Hopkins  Hospital,  first  use  of 

rubber  gloves  at,  7 
Joints,  acquired  deformities  of,  379 

congenital  dislocations  of,  379 

dislocations  of,  382,  383 

first  aid  in  injuries  of,  363 

fixation  of,  110,  117 

fractures  near,  383 

septic  infection  in,  387 

tuberculosis  of,  388 

K 

Kangaroo  tendon,  264,  270 
Kelly-Murphy  forceps,  284 
Kelly's  clamp,  384 

needles,  289 

pad,  258 

substitute  for,  347 

rectal  speculum,  288 

retractor,  287 

urethral  dilator,  294 


INDEX 


415 


Kelsey's  hemorrhoidal  clamp,  284 
Kernig's  sign,  58 
Kidney  set,  instruments  for,  325 
Knee  chest,  position,  105,  108 

fractures  of,  first  aid  in,  363 

injuries  of,  first  aid  in,  363 
Knives  (see Cutting  instruments),!  79 

care  of,  in  sterilizing,  295,  302 
Knock-knees,  379 
Knowledge  in  obscrva  ion,  190 
Koch,  Robert,  6 
Kocher's  clamp,  284 

intestinal  clamp,  284 
Kronig's  method  of  sterilizing  cat- 
gut, 269 

L 

Laboratory,  clinical,  58 
Lacerated  wound,  34 
Laceration  of  the  perineum,  397 

of  uterine  cervix,  397 
Lane  plates,  271 
Langenbeck's  retractor,  287 
Laparotomy  packers,  263 

sheet,  257 

sponges,  263 
Laryngology,  93 
Lateral  prone  position,  105 
Leg  fractures,  first  aid  in,  361 
Lesion,  56 

Lesions  of  trauma,  381 
Leucocytes,  42,  68,  72,  76 
Ligature    carriers    (see    Sewing    in- 
struments) 
Ligatures,  266 
Linear  measure,  169 
Linen  net,  celloidin,  for  skin  grafts, 

273 

Lipoma,  388 
Liquid  measure  (Apothecaries'),  170 

metric),  170,  171 
Lister,  Joseph,  4,  5,  6,  7,  95 
Lister's  bandage  scissors,  279 

needle,  289 
Liston's  amputating  knife,  279 

bone-cutting  forceps,  281 


Lithotomy  position,  103,  107 
posts,  substitutes  for,  347 

Litre,  170 

Littauer's  scissors,  279 

Local  anaesthesia,  foimulae  for,  175 
symptoms,  57 

Localizing  symptoms,  57 

Lockjaw,  49 

Long  side  T-splint,  135 

Luer's  curette,  280 

rongeur  forceps,  281 

Lues  (see  Syphilis) 

Lymphangitis,  386 

M 

Major  operation,  94 

Male  catheter,  294 

Malformations,  377 

Malignant  tumors,  24,  80,  388,  391, 
402 

Malta  fever,  30 

Many-celled  organisms,  13 

Marshall-Hall    method    of    artificial 
respiration,   317 

Martin's  bandage,  258 
curette,  280 

Mask,  operating,  256 

Massachusetts  General  Hospital  dis- 
sector, 292 

Mathieu's  needle-holder,  291 
rectal  speculum,  288 

Mayo-Robson  stomach  clamp,  284 

Mayo-Simpson  self-retaining  retrac- 
tor, 287 

Mayo's  scissors,  279 

McEwen's  chisel,  281 
gouge,  281 
osteotome,  281 

Measure  of  volume,  170 

Measurements    in    observation,    198 

Measures  of  weight,  171 

Measuring  glasses,  258 

Mechanical  causes  of  disease,  62 
derangements,  63,  89 

Medical  words,  derivation,  83 


416 


INDEX 


Medical  words,  method  of  construc- 
tion, 83,  84 

root-words,  84,  85 

prefixes,  86 

suffixes,  87 
Metacarpal  saw,  282 
Metal  splints,  135 
Metaplasia,  56 

Metre,  English  equivalent  of,  169 
Metric  system,  169 
Mickulicz  pads,  263 
Micrococci,  22,  26 
Micrococcus  gonorrhoea,  52,  91 
Milk  as  source  of  infection,  28 
Minor  operation,  94 
Moist  gangrene,  389 

heat,  386 

Moony's  ligature  carrier,  291 
Morbidity,  96 
Morphine,  administration  of.  205 

and     scopolamine,     administra- 
tion of,  233 
Mortality,  96 

surgical,  before  Lister,  3 
Mortification,  389 
Mouth,  bacteria  in,  28 

spray,  infection  by,  33 
Movement  of  cells,  10 
Mucoid  degeneration,  81 
Multiplication  of  bacteria,  19 
Murphy  button,  271 

drip,  146 
Muscle  cells,  15 
Muslin  bandage,  112 
Myoma,  388 

N 

Nail  cleaners,  256 
Nails,  care  of,  306 
Nausea,  57 

Neck,  bandages  of,  124 
Necrosis,  56,  80 

of  bone,  387 

Needles    (see    Sewing    instrumen  s), 
289,  290 

aspirating,  294 


Needles,  for  arterial  suture,  276 

hollow,  care  of.  295 
Needle-holders    (see    Sewing    instiu- 

ments),  291 

Nelson's  vaginal  speculum,  288 
Neoplasia,  57,  91 
Neoplasms,  79,  91,  383 
Nerve-cells,  15 
New-growths,  79,  91,  388 
Noble's  needle-holder,  291 
Nomenclature,  83  et  seq.,  94 
Normal,  definition  of,  16,  60 

healing,  7,  37 

Nott's  double-current  catheter,  294 
Novocaine,  175,  233 
Nucleus,  9 
Nurse,   administration   of  mcrphine 

by,  205 

assisting  anaesthetist,  317 
in    operating    room,    duties    of, 

244,  316,  317,  318 
observation  by,  189  et  seq. 
part  in  anoci-association,  234 
personal  attitude  of,  372  el  seq. 
to  self,  375 

towards  the  hospital,  374 
towards  the  patient,  372 
towards  the  public,  375 
towards  the  surgeon,  373 
responsibility  of  surgical,   7,  8, 

95,  244 

Nutrireceptors  of  cell,  78 
Nutrition  of  cells,  10,  11 


Objective  symptoms,  57 
Obligation,  surgical,  97 
Observation,  189  et  seq. 

by  nurse,  purpose  of,  189 

meaning  of,  189 

measurements  in,  198 

method  in,  190 

quantitative  judgments  in,  198 

record  of,  200 

scale  of  seven,  199 


INDEX 


417 


Obstruction,  intestinal,  393 
Ochsner's  clamp,  284 

gall-bladder  trocar  and  cannula, 

294 

(Edema,  61, 194,  381 
Ointments,  formulae  for,  177 
Oozing  from  wound,  37,  115 
Open  operation,  35 

treatment  of  burns,  151 
Operating  gowns,  257 
Operating  materials,  261  to  277 
celloidin  linen  net,  273 
classification  of,  261 
crepe  lisse,  273 
drains,  270 

drums  for  dressings,  270 
for  suturing  arteries  and  veins, 

276 

gauze  for  dressings,  271,  273 
gutta-percha  tissue,  273 
ligatures,  266,  275 
materials  to  fix  dressings,  273 
medicated  gauze,  271 
method  of  assembling,  284 
packers,  263 
retractors,  muslin,  264 
sponges,  262 
sutures,  264,  275 
unit  package  of,  275 
Operating    room,     arrangement    of, 

316 

dress,  256 
fixtures,  247 
furniture,  254 
in  private  house,  345 
nurse,  responsibility  of,  244 
nurses,  duties  of,  316 
unscrubbed  nurse,  317 
instrument  and  suture  nurse, 

318 

sponge  nurse,  318 
organization,  243 
personnel,  314 
anaesthetist,  314 
first  assistant,  315 
27 


Operating   room,   personnel,   second 

assistant,  315 

nurse  in   charge   of  instru- 
ments, 315 
nurse  in  charge  of  sponges, 

315 

unscrubbed  nurse,  315 
operator,  315 
orderly,  244,  315 
preparation  of,  312,  313 
rooms  connected  with,  246 
supplies,  256 
temperature  of,  320 
uter.sils,  255 
Operating  table,  254 

in  private  house,  345 
pad  for,  255 
Operation,  3,  8,  34,  35 
bloodless,  35 
in  private  houses,  345  et  seq. 

anaesthetic,  choice  and  dan- 
gers of,  347 
artificial  light,  346 
Kelly    pad,    substitute   for, 

347 
lithotomy  posts,  substitutes 

for,  347 
room,  choice  of,  345 

preparation  of,  345 
sterilization  of  instruments, 

water,  etc.,  347 
table,  type  and  preparation 

of,  345 

utensils  and  supplies,  345 
necessary  equipment  for,  311  et 

seq. 

for  the  anaesthetist,  311,  312 
for    the    operator    and    as- 
sistants, 312 
for  the  patient,  311 
for  scrub  nurse,  312 
for   the   unscrubbed   nurse, 

312 

nomenclature  of,  94 
open,  35 


418 


INDEX 


Operation,  plastic,  89 

preparation  of  nurse  for,  313 
preparation  of  patient  for,  213 
bowel  function,  213 
diet,  213,  216 
field  of  operation,  214 
reparative,  89 

routine  after  treatment,  215 
minor  procedures,  216 
administration  of  water,  210 
nourishment,  216 
routine  treatment  after,  271 

et  seq. 
belts,  binders  and  supports, 

221 

bladder  function,  217 
bowel  function,  219 
dressings,  220 
going  home,  220 
opiates,  2J9 
sitting  up,  220 
steps  of,  35 
team  work  at,  244 
upon  the  extremities,  steps  in, 

342  et  seq. 

upon  the  head,  steps  in,  337 
upon  the  trunk,  steps  in,  337 
Operative  hazards,  95,  97,  229,  237 
steps,  336  et  seq. 
surgery,  94 
wounds,  35 
Ophthalmology,  92 
Optimum  temperature,  11 
Organic  changes,  55 
disease,  56 
sensations,  196 
Organisms,  many-celled,  14 
single  and  many-celled,  13 
single-celled,    13 
Organization  in  many-celled   forms, 

14 

Orthopaedic  surgery,  93 
Osteoma,  388 
Osteomyelitis,  386 

set,    instruments   for,    334,    335 


Osteotome,  281 

and   chisel,   difference   between, 
281 

McEwen's,  281 
Otology,  93 
Ovarian  Syst,  401 
Oxidation  in  cells,  10 


Pack,  how  wet,  150 
Packers,  laparotomy,  263 
Packing,  uterine,  159,  272 

vaginal,  159,  272 

wounds,  366 
Pad  for  operating  table,  255 

Kelly,  258 
Puds,  271 
Pain,  37,  196 

inflammatory,   196 

localization  of,  196 

measures  for  relief  of,  204-206 

mental  attitude  toward,  207 

referred,  196 
Palliative  operation,  94 

treatment,  59 
Pallor,  194 
Palmar  splint,  135 
Palmer's  cervical  dilator,  292 
Palpation,   58 

Panhysterectomy,  steps  in,  341 
Paradoxical    incontinence    of    urine, 

227 

Paraffin  occlusion  treatment  of  burns, 
150 

wax  for  burns,  177 
Parasite,  relation  to  host  of,  28 
Parasitic  organisms,  23,  25,  29 
Passive  congestion,  148 
Paste,  bismuth,  150 

formula  for,  177 

Unna's,  150 
Pasteboard  splints,  135 
Pasteur,  Louis,  4 
Pathogenic  bacteria,  20 
Pathognomonic  symptoms,  57 


INDEX 


419 


Pathological  anatomy,  60 

changes,  meaning  of,  60 

diagnosis,  59 

histology,  60 

physiology,  60 
Pathology,  59 

surgical,   60 

Patient,  anaesthetized,  care  of,  317, 
319 

attitude  of  nurse  towards,  372 

care  of,  after  operation,  322 

comfort  and  well-being  of,  201 

draping  of,  for  examination,  355 

preparation  of,  for  operation,  213 
Pean's  clamp,  284 

pedicle  clamp,  284 

T-forceps,  284 
Peaslee's  ligature  carrier,  291 
Pelvic  abscess,  400 

set,    instruments   for,    325,    326 
Penetrating  wound,  34,  382 
Percussion,  58 
Perforation  of  intestine,  391 
Perineal  dressings,  care  of,  156 

set,  instruments  for,  331 
Perineorrhaphy,  step  in,  3-12 
Periosteal  elevators,  292 
Peritonitis,  64,  91,  224 

suppuralivc,  391 

tuberculous,  393 
Personal  attitude  of  nurse,  372 
Phagocytosis,  72,  76 
Phlegmon,  385 
Physical  causes  of  disease,  63 

signs,  57 
Physiological  salt  solutions,  formulae 

for,  176 

intravenous     administra- 
tion of,  supplies  for,  160 
supplies  for  subcutaneous 

administration  of,  160 
Pillow  splint,  361 
Placental  curette,  280 
Plaster,  adhesive,  260  (see  Adhesive 
plaster) 


Plaster-of-Paris  bandages  and  casts, 

130 

method  of  making,  133 
Plastic  operation,  89,  94 
Plating    or    wiring    set,    instruments 

for,  335 

Pleural  cavity,  infection  in,  387 
Pneumococcus,  31 
Pneumonia,  31 

postoperative,  226,  227 
Pcecilothermism,  203 
Poison,  65 
Poisoned  wound,  34 
Poliomyelitis,  anterior,  379 
Positions  (see  Postures) 

Fowler's,  150 

in  bed,  202 

Posterior  leg  splint,  135 
Postures,  101 

dorsal,    103 

dorsosacral,  103,  107 

elevated  dorsosacral  104 

erect,  106 

Fowler's  150 

genu-pcHoral,  105,  108 

horizontal  recumbent,  101 

knee-chest,  105,  108 

lateral  prone,  105 

lithotomy,  103,  107 

reversed  Trondelonburg,  102 

Sims's,  105 

Trendelenburg,  101,  107 
Pratt-Hank's  cervical  dilator,  292 
Pratt's  rectal  bougie,  294 

sigmoid  speculum,  288 

urethral  speculum,  288 
Precautions  in  infected  cases,  211 
Precursory  symptom,  57 
Predisposing  causes  of  disease,  56 
Prefixes,  86 

Premonitory  symptoms,  57 
Preparation  of  patient  for  operation, 

213 
Pressure,  bandaging  for,  116 

effects  of,  62,  211 


420 


INDEX 


Pressure,  from  bandages,  117,  210 

Presumptive  diagnosis,  59 

Probe,  silver,  292 

Probe-pointed  grooved  director,  292 

Proctoclysis,  208 

continuous,  147 
Prodromal  symptoms,  57 
Prolapse  of  the  uterus,  396 
Protective,  273 
Proteids,  81 
Protozoa,  22 
Provisional,  59 

Public,  attitude  of  nurse  towards,  375 
Pus,  42 
Putrefaction,  5 
Pyaemia,  45,  226 
Pyosalpinx,  400 


Quantitative  judgments,  198 
Quantity,  estimations  of,  199 
Quinine  and  urea  hydrochloride,  175, 
233 

R 

Rack  for  abdominal  pads,  255 
Radical  operation,  94 

treatment,  59 
Radium,  63,  402 
Rational  treatment,  59 
Reaction  to  stimuli,  12,  14,  15,  56, 

58,  60,  78 

Receptors  of  cell,  78 
Records,  180 

in  gynecological  dispensary,  351 

of  observations  by  the  nurse,  200 
Recovery  room,  246 
Rectal  irrigation,  146 

plug,  273 

set  instruments  for,  9,  327 

tubes,  258 

Red  corpuscles  of  blood,  75 
Referred  pain,  196 
Regeneration,  56 
Remedial  measures,  142 
Reparative  operation,  89 


Reproduction  of  cells,  10 
Resection,  94 

of  rectum,  instruments  for,  329 
of  rib,  steps  in,  338 
set,  instruments  for,  335 
Rest  in  treatment  of  trauma,  384 
Resting  stage  in  single-celled  organ- 
isms, 11,  20,  22 
Restlessness,  57 
Retention  of  urine,  227 
Retractors,  264,  284,  287,  289  (see 

Exposing  instruments) 
Retroflexion  of  the  uterus,  396 
Retroversion  of  the  uterus,  395 
Reverdin's  ligature  carrier,  291 

method  of  sterilizing  catgut,  269 
Reversed     Trendelenburg     position, 

101,  107 
Rhachitis,  379 
Rhinology,  93 
Rib  shears,  281 
Ribs,  fractures  of,  363 
Richardson's  retractor,  387 
Richter's  needle  holder,  291 

volsellum  forceps,  285 
Rickets,  379 

Right-angled  elbow  splint,  135 
Risks,  operative,  95,  97,  229,  237 
Rongeur  bone-cutting  forceps,  281 
Room,  examining  and  treatment,  in 
gynecological  dispensary,  352 
in  private  house,  for  operation, 

345 

operating  (see  Operating  room) 
Root-words,  84,  85 
Routine   treatment   after   operation, 

215 
Rubber  apron,  256 

articles,  care  of,  258 
drainage  tubes,  270 
gloves,  7,  257 
first  use  of,  7 
method  of  mending,  257 
method  of  putting  on,  304 
method  of  sterilizing,  302 


INDEX 


421 


Rubber  tourniquet,  258 

tubing,  258 
Rupture,   393 

.of  bladder,  383 


Salpingitis,  400 

Salpingo-oophoritis,  400 

Salt  solutions,  formulae  for,  176 

intravenous  administration  of, 

160   . 
subcutaneous     administration 

of,  160 

Sapraemia,  224 
Saprophytic  bacteria,  20 
Sarcoma,  80,  388 
Satterlee's  saw,  282 
Saws,  279,  282,  283,  332 
Gigli's  wire  saw,  282 
Key's  skull  saw,  282 
metacarpal  saw,  282 
Satterlee's  saw,  282 
Windler's  saw,  332 
Scale  of  seven,  199 
Scalpels,  278,  279 
Scar,  41 

Searching    instruments    (see    Auxil- 
iary instruments),  292,  293 
Schleich's  marble  dust  soap,  177,  256 
Schwartze's  chisel,  281 

gouge,  281 

Scissors  (see  Cutting  instruments) 
Scoliosis,  379 
Scopolamine,  233 
Scultetus  bandage,  111,  274 
Secretion  of  cells,  10 
Sensations,  organic,  196 
Sepsis,  35 

Septic  diseases,  385 
infections,  91 
in  joints,  389 
in  serous  cavities,  387 
men  and  animals  as  carriers 

of,  31,  45,  299 
wound,  34 


Septic    wound,     infection,    bacteria 
concerned  in,  45 

infections,  sources  and  modes 

of,  45 

Septicaemia,  45,  225 
Septicopya3mia,  45 
Sequelae,  56 

Serous  cavities  of  body,  3 
Serum,  antitetanic,  359 
Seven,  scale  of,  199 
Sewing  instruments,  289,  290,  291 
ligature  and  suture  carriers,  291 

aneurism  needle,  291 

Carsten's,  291 

Cleveland,  291 

Emmet's  291 

Moony's,  291 

Peaslee's,  291 

Reverdin's,  291 

Whitehead's  staphylorrhaphy, 

291 
needles,  289,  290 

Emmet's  half-curved,  289 

Glover's  needle,  289 

Halsted-Hagedorn,  289 

intestinal,  289 

Kelly's,  289 

Lister's,  289 

surgeon's  half -curved,  289 

surgeon's  full-curved,  289 

triangular  point  needle,  289 
needle-holders,  290,  291 

Hagedorn's,  291 

Hegar's,  291 

Mathieu's,  291 

Noble's,  291 

Richter's,  291 

Shafer  method  of  artificial  respira- 
tion, 369 

Sharp  hook  retractor,  286 
Sheet,  laparotomy,  257 
Shock  in  accident  cases,  371 

postoperative,  222 
Shoes,  operating,  257 
Shoulder  cap,  135 


422 


INDEX 


Shoulder  fractures,  first  aid  in,  361 
Side-chain  theory,  Ehrlich's,  77 
Signs,  58 

Graefe's,  58 

Kernig's,  58 

physical,  57 
Silk  bolting  cloth,  273 
Silkworm-gut,  266 
Silver  foil,  260,  273 

probe,  292 

Silvester  method  of  artificial  respi- 
ration, 369 
Sincerity   in   anoci-association,    235, 

236 

Sinclair's  glue,  178 
Single-celled  organisms,  13 
Simon's  retractor,  286 
Simple  fractures,  360,  382 
Sims's  curette,  280 

position,  105 

uterine  sound,  292 

vaginal  sound,  292 
Skene's  self-retaining   catheter,   294 

volsellum  forceps,  285 
Skin,  disinfection  of,  298,  299,  305 
Sleeping  sickness,  30 
Snake  bite,  34 
Soap,  256 

formula  for,  177 

neutral,   177 
Solution  of  continuity,  381 

Dakin's,  161 
Solutions,  173,  178 

basins  for,  254 

in  gynaecological  dispensary,  355 

preparation  of,  173,  178 
Sound,  urethral,  294 

uterine,  292 
Specialism,  surgical,  92 
Specialization  of  cell  activities,  12 
Specific  disease,  56 

treatment,  59 

Specula,  288,  289  (see  Exposing  in- 
struments) 
Spina  bifida,  378 


Spirilla,  18 

Splints,  blankets,  361 

Blake,  138 

coaptation,  138 

extension,  138 

improvised  in  first  aid,  360 

Listen,   138 

lockup,  138 

material  for  fastening,  137 

materials  for,  260 

metal,  138 

moulded,  138 

padding  of,  136 

pillow,  361 

pressure  by,  62,  211 

Thomas,  138,  362 

wooden,  138 
Sponge  forceps,  284 
Sponges,  gauze,  36,  262 
Spoon  curette,  280 
Spores,  11,20,22 
Spray  of  carbolic  solution,  5 
Stability  in  cell  life,  14 
Staining  cell  and  nucleus,  9 
Staphylococcus  pyogenes  albus,  46, 
386,  398 

pyogenes  aureus,  46 
Steam,  articles  to  be  sterilized  by, 
301 

sterilization  by,  300 

sterilizer,  248 

under  pressure,  sterilization  by, 

7,301 

Stenosis  of  vagina,  395 
Sterilization,  by  heat,  300 

apparatus  for,  247  et  seq. 

by  steam  under  pressure,  7,  248, 

301 
apparatus  for,  248,  250 

definition  of,  298 

in  operating  room,  248  to  253, 
301 

in  private  house,  345,  347 
Sterilized     outfit,     assembling     and 
handling,  302 


INDEX 


423 


Sterilizers,  247  et  seq. 

dressing,  248 

for  steam  under  pressure,  248 

hot-air,  247 

instrument,  251 

untensil,  251 

water,  253 
Sterilizing   cutting  instruments,   295 

room,  246 

Stick  sponge  forceps,  284 
Stimulus,  11,  12,  14,  15,  38,  56,  60, 

64,  70,  78 
Stomach,    acute    dilatation    of,    223 

carcinoma  of,  391 

and    intestine    set,    instruments 
for,  325 

bacteria  in,  28 

clamps,  284 

tubes,  258 

ulcer  of,  390 
Stone  searcher,  292 
Stones  in  bladder,  etc.,  81 
Stools,    observation    and   record   of, 

195,  394 

Strangulated  hernia,  394 
Streptococcus  infection  of  throat,  28 

pyogenes,  46,  386,  398 
Stretcher,  wheel,  254 
Stricture  of  the  oesophagus,  320 
Struma,  389 

Styptic  drugs  in  hemorrhage,  367 
Subcutaneous  wound,  34 
Subjective  symptoms,  57,  196 
Suffixes,  87 

Suggestion  in  anaesthesia,   239,   240 
Super-technic,  307 
Supply  room,  246 
Supports,  abdominal,  postoperative, 

221 

Suppression  of  urine,  228 
Suppurating  wound,  34 
Suppuration  in  wounds,  42 
Suppurative  peritonitis,  391 
Surgeon,  attitude  of  nurse  towards, 
373 


Surgeons'        half-    and    full-curved 

needles,  289 
Surgery,  clinical,  82 

definition  of,  89 
Surgical  obligation,  97 

infections,  385 

pathology,  60 

specialism,  92 

Suture   carriers    (see   Sewing  instru- 
ments) 
Sutures,  264 

absorbable,  265 

non-absorbable,  265 
Suturing  of  arteries  and  veins,  276 
Swabs  (see  Sponges) 
Swelling  of  limb  below  bandage,  117 
Symptomatic  treatment,  59 
Symptoms,  57 

classification  of,  57 

constitutional,  57 

definitions,  57,  193,  196 

focal,  57 

index,  193 

local,  57 

objective,  57,  193 

observation  of,  192 

of  trauma,  383 

pathognomonic,  57 

premonitory,  57 

requiring   that   the   surgeon   be 
summoned,  192 

significance  of,  191 

subjective,  57, 196 
Syndrome,  57 
Syphilis,  organism  of,  51 


Table  of  fractional  doses,  163 
operating,  pad  for,  255 
in  private  house,  345 

Tait's  clamp,  284 

ovarian  trocar,  294 

Tampons,  272 

T-bandage,  111,  274 

Team  work  at  operation,  244 


424 


INDEX 


Technic,  anoci-association,  232 

aseptic,  8,  299  et  seq. 

Carrel-Dakin,  160 

definition  of,  296 

surgical,  three  divisions  of,  297 
Temperature,  effect  on  cell  life,  11 

of  operating  room,  320 
Tenaculum,  285 
Tenotomy  knives,  279 
Tetanus,  78 

antitetanic  serum  in  prevention 
of,  359 

bacillus,  49,  359 
Thermal  death  point  of  bacteria,  298 

of  human  tissue  cells,  64 
Thigh,  fractures  of,  first  aid  in,  362 
Thirst  after  anaesthetic,  208 
(Thomas's  curette,  280 
Thomas's  splint,  362 
Thompson's  stone  searcher,  292 
Thoracotomy,  338 
Thorax,  bandages  of,  125 
Threshold  of  stimulus,  12 
Throat,  bacteria  in,  28,  31 
Thrombosis  of  mesenteric  artery,  394 
Tissue  changes,  79 

gutta-percha,  273 
Topical  symptoms,  57 
Tourniquet,  improvised,  366 

rubber,  258 
Towels,  257 
Toxins,  76 

Trachelorrhaphy  set,  instruments  for, 
331 

steps  in,  342 

Transmission  of  infection,  modesof,  32 
Transplantation  of  tendons,  379 
Transportation  of  accident  cases,  363 
Transposition   of  tables   of  weights 

and  measures,  172 
Trauma,  89,  381 
Traumatic  fever,  38 
Treatment,  59 

active,  59 

definitions,  59 


Treatment,  empirical,  59 

expectant,  59 

of  trauma,  384 

palliative,  59 

radical,  59 

rational,  59 

specific,  59 
•  symptomatic,  59 
Trendelenburg  position,  101 
Trephines,    279,    280    (see    Cutting, 
instruments) 

DeVilbiss's,  280 

Gait's,  280 

Hudson's,  330 
Trephining,  3 

steps  in,  337 
Treponema  pallidum,  51 
Triangular  bandage,  113 

point  needle,  289 
Trocar  and  cannula,  294 

care  of,  295 

Trunk,  operation  upon,  steps  in,  337 
Tube  drains,  270 
Tubercle  bacillus,  50,  91 
Tuberculosis,  28,  51,  387 

surgical,  lesions  of,  388 

surgical,  treatment  of,  388 
Tuberculous  peritonitis,  393 
Tubes,  Carrel-Dakin,  163,  164 
Tubing,  rubber,  258 
Tubo-ovarian  abscess,  400 
Tumors,  79,  91,  388 
Two-stage  operation,  94 
Typhoid  fever,  28,  31 


Ulcer,  91 

of  duodenum,  390 

of  stomach,  390 
Ulcerative  appendicitis,  391 
Umbilical  scissors,  279 
Unicellular  organisms,  13 
Unknown  invaders,  23 
Unna's  paste,  150 
Urethral  sound,  294 


INDEX 


425 


Urine,  paradoxical  incontinence  of,  228 

retention  of,  207,  227 

retention  with  overflow,  227 

suppression  of,  228 
Utensil  sterilizer,  251 
Uterine  packing,  supplies  for,  160 

packs,  210,  272 

sound,  Sims's,  292 
Uterus,  cancer  of,  402 

fibroid  tumor  of,  401 

prolapse  of,  396 

retroflexion  of,  396 

retroversion  of,  395 

V 

Vagina,  atresia  of,  395 

Vaginal  Douches,  formula  for,  177 

technic  of,  155 
packing,  272 

supplies  for,  160 
packs,  210 
Vaginitis,  399 

Van  Buren's  sequestrum  forceps,  285 
Varicose  veins,  89 

hemorrhage  from,  367 
Venous  hemorrhage,  381 
Velpeau  bandage,  127 

bone-cutting  forceps,  281 
Verbal     suggestion     in     anaesthesia, 

239,  240 

Viruses,  filterable,  23 
Volkmann's  curette,  280 
retractor,  286 
sliding  rest,  136,  140 
Volvulus,  89 
Vomiting,  57 
Von  Blunk's  clamp,  284 
Vulvitis,  399 

W 

Wadding,  hospital,  260 
Wale's  rectal  bougie,  294 
Water,  absorption  of,  in  the  intes- 
tine, 208 
administration  of,  207,  384,  386 

in  infections,  208 
by   mouth,    when    to   be   with- 
held, 209 


Water,  necessary  for  cell  life,  11 

sterilizers,  253 

Wathen's  cervical  dilator,  292 
Waxy  degeneration,  81 
Webbing,  137 

Weiss's  urethral  dilator,  294 
Well-being  of  patient,  measures  for, 

201 

Wet  dressings,  150,  204,  386 
Wheel  stretcher,  254 
Whitehead's  ligature  carrier,  291 
Wick  drains,  271 
Windler's  saw,  332 
Wiring   or   plating  set,   instruments 

for,  335 

Wooden  splints,  135 
Wounds,  3,  5,  7,  16,  34,  41 
accidental,  34 

first  aid  in,  357 
dressings  for,  271 
infected,  3,  5,  7,  16,  31,  34,  41 

45,  299 
healing  in,  44 
symptoms  of,  43,  45 
infection  of,  bacteria  concerned 

in,  46 

fever  in,  41 
postoperative,  224 
materials  for  dressing,  262 
of  special  structures,  382 
operative,  35 
septic  infection  of,  sources  and 

modes,  45 

Wright's  intestinal  clamp,  284 
Wrist  fractures,  first  aid  in,  360 

X 

X-ray,  63,  383,  402 


Young's    retractor,     prostatic,     287 
vesical,  287 

Z 

Zinc,  carbonate,  precipitated,  206 
oxide,  206 

ointmont,  177 


THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
STAMPED  BELOW 

AN  INITIAL  FINE  OF  25  CENTS 

WILL  BE  ASSESSED  FOR  FAILURE  TO  RETURN 
THIS  BOOK  ON  THE  DATE  DUE.  THE  PENALTY 
WILL  INCREASE  TO  SO  CENTS  ON  THE  FOURTH 
DAY  AND  TO  $1.OO  ON  THE  SEVENTH  DAY 
OVERDUE. 

BIOLOGY  LIBRARY 


MAR  27  1941 

NOV  3  °  iq 

18 

Otff  "95  1949 

LD  21-10m-7,'39  , 

WOIOCT 


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